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THE  CONTROL  OF  HOOKWORM   DISEASE 
BY  THE  INTENSIVE  METHOD 


THE  CONTROL  OF 
HOOKWORM   DISEASE 

BY  THE 

INTENSIVE  METHOD 


BY 

H.  H.  HOWARD,  M.D. 

DIRECTOR    FOR   THE   WEST   INDIES 


PUBLICATION    NO.   8 


THE  ROCKEFELLER   FOUNDATION 
INTERNATIONAL  HEALTH   BOARD 

NEW  YORK  CITY 
I919 


THB-PLIMPTOM-PRBSS 

NORWOOD-  MASS-  U-S- A 


Biomedical 
Library 

<7  Ch  tj 


INTERNATIONAL  HEALTH   BOARD 

OFFICERS    AND   MEMBERS 

George  E.  Vincent,  Chairman 

WiCKLiFFE  Rose,  General  Director 

Hermann  M.  Biggs 

Wallace  Buttrick 

Simon  Flexner 

Frederick  T.  Gates 

William  C.  Gorgas 

Starr  J.  Murphy 

Walter  H.  Page 

John  D.  Rockefeller,  Jr. 

William  H.  Welch 


Edwin  R.  Embree,  Secretary 


ADMINISTRATIVE  STAFF 

Wickliffe  Rose,  General  Director 
John  A.  Ferrell,  M.D.,  Director  for  the  United  States 
Victor  G.  Heiser,  M.D.,  Director  for  the  East 
Hector  H.  Howard,  M.D.,  Director  for  the  West  Indies 
Ernst  C.  Meyer,  Director  of  Surveys  and  Exhibits 


AUTHOR'S  NOTE 

In  Publication  No.  i  of  the  International 
Health  Board,  entitled  "The  Eradication  of 
Ankylostomiasis,"  were  described  the  methods 
employed  in  the  work  directed  against  hook- 
worm disease  in  British  Guiana  during  1914. 
The  procedure  there  set  forth  has  since  come  to 
be  known  as  the  "Intensive  Method."  It  is 
being  used  in  many  countries  in  which  meas- 
ures against  hookworm  disease  have  been  under- 
taken, and  has  been  found  to  be  applicable 
under  a  great  variety  of  conditions. 

The  continued  demand  for  Publication  No.  i 
has  led  to  the  preparation  of  this  new  edition, 
which  aims  to  bring  the  description  of  this 
working  plan  up  to  date  by  showing  the  modi- 
fications and  developments  which  it  has  under- 
gone since  the  original  pamphlet  was  issued. 
Unlike  Publication  No.  i,  which  dealt  entirely 
with  the  work  in  the  Peter's  Hall  district  of 
British  Guiana,  the  present  publication  is  in- 
tended to  cover  not  the  specific  details  of  a 
campaign  in  any  one  country,  but  the  general 
procedure  followed  in  conducting  any  demon- 
stration against  hookworm  disease  by  the  in- 
tensive method.  u    u    u 

New  York  Cnr, 
December  31,  19 18 


CONTENTS 

HAPTER  PAGE 

I.   Problem  of  Hookworm  Control 13 

I.  Magnitude  of  the  Problem.  2.  Theo- 
retical   Simplicity    of    Control    Measures. 

3.  Practical     Difficulties     Experienced     in/^ 
Carrying  out  Control  Measures.      4.  Re- 
sponsibility of  Local  Agencies. 

II.   Intensive     Method    of    Attacking    the 

Disease 20 

5.  Definition    of    the    Intensive    Method.     ^ 

6.  Development  of  the  Intensive  Method. 

III.  Selection  of  Area  of  Operation 26 

7.  Size  of  Area.  8.  Rate  of  Handling  the 
Population.  9.  Duration  of  Work  in  Area. 
10.  Division  of  Area  into  Nurses'  Districts. 

II.  Consolidation  of  Nurses'  Districts. 

IV.  Publicity  and  Educational  Measures...       31 

12.  Education  the  Primary  Aim  of  Intensive 
Campaign.  13.  Purpose  of  Educational 
Work.  14.  Lectures.  15.  Distribution  of 
Literature.  16.  The  Press.  17.  Micro- 
scopic Demonstrations.  18.  Nurses  as  a 
Means  of  Publicity. 

V.  Working  Force 37 

19.  Size  of  Working  Staff.  20.  Branch 
Offices  in  Area.  21.  Duties  of  the  Medical 
Director.  22.  Relation  of  Medical  Direc- 
tor to  Government.  23.  Relationship  of 
Medical  Director  to  the  People.  24.  Duties 
of  Clerical  Force.  25.  Duties  of  Chief 
9 


lO  CONTENTS 

CHAPTER  PAGE 

Clerk.  26.  Duties  of  Chief  Microscopist. 
27.  Duties  of  Microscopists.  28.  Selection 
of  Microscopists.  2Q.  Training  of  Micros- 
copists. 30.  Duties  of  Nurses.  31.  Duties 
of  Chief  Nurse.  32.  Selection  of  Nurses. 
33.  Training  of  Nurses.  34.  Duties  of 
Caretakers.  35.  Salaries  of  Subordinate 
Employes.  36.  Allowances  for  Subordi- 
nate Employes. 

VI.   Census  Taking 53 

37.  Necessity       for      Accurate       Census. 

38.  Method  of  Taking  Census. 

VII.  Microscopic  Laboratory 55 

39.  Importance     of     Laboratory     Work. 

40.  Variations  in  Microscopic  Technique. 

41.  Original  Technique  in  British  Guiana. 

42.  Standard  Technique  of  Intensive 
Method.  43.  Advantages  of  Standard 
Technique.  44.  Modified  Technique  to 
Facilitate  Process  of  Examination. 
45,  Average  Findings  on  Successive  Slides 
Examined.  46.  Preparation  of  Specimens 
for  the  Centrifuge.  47.  Technique  of  Ex- 
amination Following  Treatment.  48.  Num- 
ber of  Specimens  Examined  Daily. 

VIII.  Treatment 69 

49.  Thymol     Preferred     as     Anthelmintic. 

50.  Daily-dose  Method  of  Administering 
Thymol.  51.  Intensive,  or  Weekly-dose, 
Method  of  Administering  Thymol.  52.  The 
Medically  Unfit  for  Treatment.  53.  Di- 
rections for  Taking  Thymol.     54.  Interval 


CONTENTS  II 

PAGE 


between  Treatment  with  Thymol  and  Re- 
examination. 55.  Number  of  Thymol 
Treatments  Necessary  to  Cure.  56.  Is 
Thymol  a  Dangerous  Drug?  57.  Prepara- 
tion of  Thymol  for  Administration. 
58.  Toxic  Effects  of  Thymol.  59.  Minor 
Symptoms  of  Thymol  Poisoning.  60.  Seri- 
ous    Symptoms     of    Thymol     Poisoning. 

61.  Treatment      of     Thymol      Poisoning. 

62.  Use  of  Oil  of  Chenopodium  as  an  An- 
thelmintic. 63.  Schiiffner  &  Vervoort 
Method  of  Administering  Chenopodium. 
64.  Weiss  Method  of  Administering  Che- 
nopodium. 65.  Method  of  Administer- 
ing Chenopodium  Recommended  by  Un- 
cinariasis Commission  to  the  Orient. 
66.  Interval  between  Treatment  with  Che- 
nopodium and  Re-examination.  67.  Prep- 
aration of  Chenopodium  for  Administra- 
tion. 68.  Measurement  of  Oil  of  Chenopo- 
dium.   69.  Toxic  Effects  of  Chenopodium. 

70.  Symptoms  of  Chenopodium  Poisoning. 

71.  Treatment  of  Chenopodium  Poisoning. 

IX.   Sanitary  Measures  for  Prevention 95  ^ 

72.  Necessity  of  Preventing  Soil  Pollution. 

73.  How  the  Sanitary  Problem  is  Defined. 

74.  Types  of  Latrines  to  Prevent  Soil  Con- 
tamination. 

X.   Per  Capita  Cost 99   >^ 

75.  Importance  of  Cost  Element.  76.  How 
"Per  Capita  Cost"  is  Figured,  'j'j.  Cost 
Indices  of  West  Indies  Intensive  Work. 


12  CONTENTS 

CHAPTER  PAGE 

XL   Conclusion 103 

78.  Wide  Applicability  of  Intensive  Plan. 

79.  Educational  Value  of  Intensive  Meas- 
ures. 80.  Intensive  Method  as  Means  of 
Gaining  Good-will  of  Populace. 

Illustrations 111-118 


APPENDICES 

PAGE 

I,   Results  Accomplished 121 

II.  Forms  used  in  Intensive  Work 123 

I.  Census  Book.  2.  Case-Record  Book. 
3.  Microscopic  Report  Sheet.  4.  Treat- 
ment Book.  5.  Nurses'  Reports:  Daily, 
Weekly,  Summary.  6.  Diary,  Educa- 
tional Work.  7.  Geographical  Area  Re- 
port on  Completed  Work.  8.  Quarterly 
Report  on  Completed  Work.  9.  Quarterly 
Report  on  Work  in  Progress.  10.  Special 
Monthly  Report  for  the  Information  of 
Regional  Directors.  11.  Narrative  Re- 
port. 12.  Budget.  13.  Quarterly  and 
Yearly  Financial  Reports. 

III.  List  of  Standardized  Supplies  and  Prices.     165 

IV.  Dosage  Table 168 

V.   General  Instructions  for  Nurses 169 

VI.   Contract  with  Subordinate  Employes...     172 

VII.   Sample  Circular  Used  in  British  Guiana.     174 

VIII.   Description  of  Special  Centrifuge 176 


I 

PROBLEM  OF  HOOKWORM 
CONTROL 

1.  Magnitude  of  the  Problem.  Hookworm 
disease  is  found  in  practically  all  countries 
which  lie  in  the  tropical  and  sub-tropical  zones, 
extending  from  parallel  36  degrees  north  to 
parallel  30  degrees  south.  More  than  half  the 
population  of  the  globe  lives  in  this  area.  The 
control  of  this  disease  is  therefore  an  under- 
taking of  enormous  magnitude,  which  can  be 
accomplished  only  by  permanent  agencies  work- 
ing over  a  long  period  of  time. 

2.  Theoretical  Simplicity  of  Control  Meas- 
ures. There  is  probably  no  other  disease,  cer- 
tainly no  other  parasitic  disease,  of  which  our 
knowledge  is  so  complete  as  of  hookworm  dis- 
ease, and  for  which  we  have  two  or  more  specific 
drugs.  There  is  not  a  stage  in  the  life-cycle  of 
the  hookworm  with  which  we  are  not  thor- 
oughly familiar,  from  the  moment  the  egg 
reaches  the  soil  in  the  feces  of  its  former  host 
and  hatches  into  the  larva,  throughout  all 
the  stages  of  development,  until,  in  its  encysted 
stage,  it  enters  the  human  body  and  finally 
reaches  the  small  intestine,  there  to  live  for 
eight  or  ten  years  and  to  reproduce  its  kind 

13 


14  INTERNATIONAL   HEALTH    BOARD 

by  countless  thousands.  Every  detail  of  its 
life-story  and  of  the  environment  necessary 
for  its  development  has  been  made  completely 
known  to  us  by  the  researches  of  scientists. 

With  such  thorough  knowledge  it  has  been 
an  easy  task  to  elaborate  a  perfect  theory  for 
the  prevention  of  the  disease.  Only  one  thing 
is  necessary:  that  is,  to  prevent  soil  pollution, 
or,  in  other  words,  to  keep  the  hookworm  ova 
from  reaching  the  soil,  where  they  can  hatch 
and  develop  into  infective  larvae.  If  those 
who  have  hookworm  disease  can  be  located  and 
cured,  and  if  we  can  prevent  others  from  con- 
tracting the  disease,  then,  theoretically,  com- 
plete eradication  is  an  accomplished  fact. 

3 .  Practical  Difficulties  Experienced  in  Carry- 
ing out  Control  Measures.  Although  the  prob- 
lem of  complete  eradication  seems  simple  on 
paper,  it  is  not  so  in  fact.  Many  difficulties 
arise  to  prevent  working  it  out  to  the  end. 
Virtually  every  difficulty,  however,  may  be 
rightly  attributed  to  one  cause:  lack  of 
proper  co-operation  on  the  part  of  the  people 
who  are  to  be  most  benefited.  This  is  strangely 
true  of  every  undertaking,  however  benevo- 
lent in  nature,  where  voluntary  co-operation 
on  the  part  of  the  masses  is  a  factor  for  suc- 
cess. To  accomplish  the  complete  eradication 
of   hookworm    disease    in    any    area   we    need 


PROBLEM    OF   HOOKWORM    CONTROL  1 5 

only  to  make  a  microscopic  examination  of 
every  one  living  therein,  to  treat  every  one 
found  infected  until  he  is  cured,  and  to  bring 
about  the  installation  and  use  of  sanitary  con- 
veniences that  will  put  an  end  to  further 
pollution  of  the  soil.  But  there  are  obstacles 
in  the  way  of  each  of  these  apparently  easy 
steps. 

a.  The  examination  of  every  individual  in  a 
given  area  will  rarely,  if  ever,  be  possible. 
There  will  always  be  those,  few  or  many  as 
the  case  may  be,  who  will  refuse  to  submit 
specimens.  A  false  sense  of  modesty  will  de- 
ter some;  others,  because  of  social  promi-  • 
nence,  wealth,  or  intellectual  attainment,  will 
take  it  for  granted  that  they  are  immune  to 
the  disease.  Mildly  infected  persons,  feeling  in 
good  health  and  believing  they  have  no  need 
of  treatment,  will  not  be  convinced  that,  as 
carriers,  they  are  dangerous  to  their  communi- 
ties. A  few  will  be  openly  hostile,  fancying 
that  they  see  in  the  campaign  an  attempt  to 
interfere  with  their  personal  liberties;  while  the 
full  co-operation  of  others  will  sometimes  be 
withheld  through  ignorance,  superstition,  in- 
difference, or  neglect. 

b.  Cure  depends  upon  the  willingness  of  the 
patients  to  take  treatments  for  a  sufficient 
length  of  time.    As  in  the  case  of  examination. 


l6  INTERNATIONAL   HEALTH    BOARD 

and  for  the  same  reason,  there  are  some  who 
are  unwilling  to  be  treated,  even  though  they 
have  been  examined  and  found  infected  with 
the  parasites.  There  are  others  who  lose  pa- 
tience and  abandon  treatment  short  of  cure,  and 
a  small  number  who  must  be  refused  treatment 
because  they  are  suffering  from  other  diseases 
or  conditions  which  prohibit  the  use  of  an 
anthelmintic.  Usually  the  number  refusing  or 
abandoning  treatment  is  smaller  than  that  re- 
fusing examination  in  the  first  instance. 

c.  The  failure  of  the  people  to  give  perfect 
co-operation  in  these  first  two  phases  of  a  cam- 
paign must  result  in  the  main  from  misinforma- 
tion and  misunderstanding;  it  is  chiefly  here 
that  the  patience,  persistence,  and  tact  of  the 
medical  director  and  of  the  nurses  come  into 
play. 

d.  The  installation  and  use  of  proper  sani- 
tary conveniences  to  prevent  further  soil  pollu- 
tion it  is  possible  to  bring  about.  This  has 
been  proved  in  some  of  the  West  Indian  colo- 
nies. Compulsory  laws  with  penalties,  if  en- 
forced, will  secure  results;  but  better  and 
much  more  to  be  desired  are  the  results  ob- 
tained by  the  education  and  enlightenment  of 
the  public  to  the  point  where  eventually  it  will 
demand  such  improvements.  After  sanitary 
conveniences    are    installed,    we    still    face    the 


PROBLEM    OF   HOOKWORM    CONTROL  I J 

difficulty  of  holding  the  people  to  the  use  of 
them.  This  has  not,  however,  proved  in  our 
experience  the  hopeless  task  that  some  have 
thought  it  to  be.  In  the  West  Indies,  with 
their  mixed  population,  the  patient,  tactful, 
and  yet  firm  handling  of  this  question  has 
brought  really  remarkable  results. 

e.  If  it  were  possible  to  accomplish  per- 
fectly the  above  purposes  of  the  campaign, 
there  would  still  remain  for  a  time  the  danger 
of  re-infection  from  hookworm  larvae  already 
in  the  soil,  which  we  know  live,  under  favor- 
able conditions,  for  some  months.  Because  of 
the  labor  involved,  it  is  often  impracticable  to 
attempt  to  locate  areas  where  the  soil  is  in- 
fected with  hookworm  ova  and  larvae;  and  if 
such  areas  were  located  they  would  probably 
be  too  extensive  to  justify  attempts  to  render 
them  innocuous  or  to  keep  people  away  from 
them. 

Attempts  at  the  destruction  of  hookworm 
ova  and  larvae  in  the  soil  by  the  use  of  chemi- 
cals have  not  been  very  successful.  In  a  paper 
read  befoi'e  the  Society  of  Tropical  Medicine 
and  Hygiene  by  Sir  Thomas  Oliver  in  1910, 
the  statement  is  made  that:  "The  one  salt 
which  has  given  the  most  satisfactory  results 
all  around  is  iron  sulphate.  It  is  estimated 
that  one  ton  of  this  in  a  one-per  cent  solution 


1 8  INTERNATIONAL   HEALTH    BOARD 

would  cover  a  length  of  sixty  miles  more  than 
a  yard  wide  and  one-third  of  an  inch  deep." 
This  solution  was  used  to  a  limited  extent  in 
the  first  organized  effort  against  the  disease  in 
British  Guiana,  but  it  was  most  difficult  really 
to  prove  its  efficiency.  A  more  practical  step 
was  to  burn  brush  and  trash  piles  on  spots 
likely  to  be  infected,  such  as  sites  of  surface 
closets,  stooling  places  in  thickets  and  in  the 
cane-fields,  and  vegetable  patches. 

It  would  be  possible,  of  course,  to  meet  these 
particular  difficulties  by  keeping  the  entire  pop- 
ulation under  observation  until  sufficient  time 
had  elapsed  for  all  hookworm  larvae  in  the  soil 
to  die  —  probably  about  ten  months;  or  by 
returning  to  the  area  to  find  and  cure  the  cases 
resulting  from  such  re-infection. 

4.  Responsibility  of  Local  Agencies.  The 
International  Health  Board  does  not  undertake 
on  its  own  account  to  relieve  and  control  hook- 
worm disease  in  any  country.  If  the  work  is 
to  be  successful,  the  state  or  country  in  which 
the  infection  exists  must  assume  the  burden 
and  responsibility.  The  Board  has  had  the 
privilege  of  sharing  in  the  work  in  various 
countries,  however,  by  making  contributions 
toward  its  support  and  by  lending  a  few  well- 
trained  men  to  aid  in  its  organization.  This 
co-operative  effort  is  intended  in  most  instances 


PROBLEM  OF  HOOKWORM  CONTROL       I9 

to  serve  as  a  demonstration,  which,  by  proving 
the  feasibiHty  of  attaining  the  end  in  view  at  a 
non-prohibitive  cost,  will  lead  to  the  establish- 
ment of  permanent  agencies  to  extend  the 
work  to  wider  fields. 

In  its  co-operative  efforts  with  the  different 
states  and  countries,  the  Board  leaves  the  pre- 
ventive side  of  the  problem  —  that  of  securing 
the  installation  or  improvement  of  latrines 
followed  by  the  continued  maintenance  and  use 
of  them  as  a  safeguard  against  infection  and 
re-infection  —  entirely  in  the  hands  of  the 
local  governments.  Though  its  field  forces 
devote  a  certain  proportion  of  their  time  to 
educating  the  people  in  sanitation,  this  is  but 
an  incident  of  the  Board's  work,  its  immedi- 
ate object  being  the  examination  of  the  people 
and  the  treatment  and  cure  of  those  infected. 


II 

INTENSIVE  METHOD  OF  ATTACKING 
THE  DISEASE 

5.  Definition  of  the  Intensive  Method.  The 
intensive  method  may  be  briefly  defined  as 
an  attempt  "to  approximate,  as  nearly  as  prac- 
ticable, the  complete  relief  and  control  of  hook- 
worm disease  within  a  given  area."  ^  The  plan 
of  operation  comprises  two  undertakings,  each 
with  its  own  agency.  The  first  of  these  under- 
takings, for  the  maintenance  of  which  the 
International  Health  Board  contributes  funds, 
endeavors  to  treat  until  cured  all  infected  per- 
sons dwelling  within  the  area;  the  second, 
financed  by  the  government  and  operated  by 
its  sanitary  organization,  aims  to  make  effec- 
tive such  measures  as  will  prevent  re-infection. 
The  scheme  for  treating  the  infected  requires: 
mapping  the  territory,  locating  roads,  streams, 
villages,  houses;  taking  a  census  of  the  popu- 
lation, numbering  the  houses  in  which  the 
people  live,  recording  name,  age,  sex,  race, 
and  post-office  address;  making  microscopic 
examination  of  the  entire  population;  putting 
under  treatment  all  persons  found  infected; 
and  continuing  treatment  of  each  patient  until 
microscopic  examination  following  a  standard- 

^  First  Annual  Report,  International  Health  Board,  p.  28. 

20 


METHOD   OF   ATTACKING   THE   DISEASE  21 

ized  procedure  shows  that  a  cure  has  been 
effected. 

While  this  work  Is  being  carried  on,  a  sys- 
tematic effort  Is  made  by  means  of  pubHc  lec- 
tures, the  distribution  of  literature,  newspaper 
articles,  and  house-to-house  visits,  to  educate 
the  people,  not  alone  with  regard  to  the  cure 
and  prevention  of  hookworm  disease,  but  also 
as  to  the  dangers  of  soil  pollution  and  Its  close 
relationship,  as  a  causative  factor,  to  many 
other  diseases. 

This  method  of  conducting  Intensive  opera- 
tions In  well  defined  areas  has  advantages  that 
are  worthy  of  special  note:  namely,  the  work 
Is  definite  and  thorough  and  closely  approxi- 
mates completeness;  and  where  the  sanitary 
work  keeps  pace  with  the  work  of  treatment 
and  cure,  the  results  are  lasting.  By  this 
means  the  government  is  enabled  to  begin  a 
definite  sanitary  work  on  the  basis  of  an  almost 
insignificant  expenditure,  and  to  train  and 
enlarge  its  sanitary  force  gradually  as  the  work 
is  extended  from  area  to  area,  and  as  the  people 
are  educated  to  the  point  of  giving  greater 
co-operation. 

6.  Development  of  the  Intensive  Method. 
It  was  in  British  Guiana  on  March  12,  1914, 
that  work  by  the  Intensive  method  was  under- 
taken   by    a    foreign    country    In    co-operation 


22  INTERNATIONAL   HEALTH    BOARD 

with  the  International  Health  Board  for  the 
first  time.  Following  the  visit  to  this  colony 
in  October,  191 3,  of  the  Board's  General  Di- 
rector, a  working  plan  and  budget,  prepared 
by  the  Surgeon  General  with  the  assistance  of 
Dr.  J.  E.  A.  Ferguson,  Medical  Officer  of 
Peter's  Hall  district,  were  submitted  to  the 
Board.  This  plan  and  budget  were  adopted, 
and  it  was  decided  to  select  a  medical  district 
as  the  area  of  operation  in  the  preliminary 
campaign. 

The  Peter's  Hall  district,  just  south  of  the 
city  of  Georgetown,  was  chosen.  This  district 
is  approximately  eight  miles  long  and  from  one 
to  three  miles  wide,  with  a  population  of  14,000 
people,  exclusive  of  the  indentured  labor  on  the 
sugar  plantations.  It  contains  few  isolated 
dwellings.  The  people  live  in  a  chain  of  villages, 
varying  in  size  from  200  to  4,000  inhabitants, 
lying  along  the  east  bank  of  the  Demerara 
river.  The  indentured  plantation  laborers  were 
not  to  be  dealt  with,  as  they  were  already  being 
handled  effectively  by  Dr.  Ferguson  at  the 
expense  of  the  plantation  owners. 

The  writer,  who,  as  a  member  of  the  medical 
staff  of  the  International  Health  Board,  had 
been  selected  to  co-operate  with  the  Colonial 
government  in  carrying  on  the  work,  arrived 
in  Georgetown  on  March  9,  1914.     It  became 


METHOD    OF   ATTACKING   THE    DISEASE  23 

at  once  evident  that  there  were  features  of 
the  problem  in  British  Guiana  which  neither 
the  work  conducted  against  hookworm  disease 
in  the  United  States  by  the  Rockefeller  Sani- 
tary Commission,  nor  the  local  efforts  in  the 
colony  to  control  it  among  the  indentured 
laborers  on  the  plantations,  had  encountered. 
In  the  United  States  the  sanitary  conditions 
are  not  made  worse  by  heavy  tropical  rains. 
Moreover,  the  temperature  in  the  winter  months 
not  only  compels  the  people  to  wear  shoes,  thus 
protecting  themselves  from  infection  as  well  as 
from  cold,  but  also  kills  off  hookworm  larvae 
in  the  soil.  In  British  Guiana  the  temperature 
is  always  warm.  The  people  go  barefoot  the 
year  round,  and  at  certain  seasons  there  are 
heavy  rains  almost  daily. 

In  the  United  States  the  population  that 
had  been  handled  was  made  up  of  blacks  and 
whites  only,  and  was  intelligent  enough  to  be 
amenable  to  reason.  In  British  Guiana  the 
indentured  labor  that  had  been  and  was  being 
handled  was  made  up  almost  entirely  of  East 
Indians  subject  to  estate  discipline.  But  in 
the  Peter's  Hall  district,  on  the  other  hand,  the 
population  was  very  heterogeneous  and  diffi- 
cult to  influence.  There  were  East  Indians  who 
had  served  out  their  indenture,  and  who,  being 
no  longer  subject  to  discipline,  were,  like  the 


24  INTERNATIONAL   HEALTH    BOARD 

rest  of  the  population,  intolerant  of  it.  There 
were  numbers  of  Portuguese,  especially  sus- 
ceptible to  the  disease,  severely  infected,  and  yet 
stubbornly  indifferent  to  all  efforts  made  to 
cure  them.  There  were  Chinese,  who  are 
averse  to  taking  medicine  of  any  kind  unless 
they  are  suffering  acute  pain;  and  blacks,  the 
more  ignorant  of  whom  gave  trouble  all  along. 
Only  the  "coloreds"  could  generally  be  de- 
pended upon  for  co-operation. 

The  task  of  unifying  all  these  diverse  ele- 
ments of  population  and  of  creating  among 
them  an  active  common  interest  in  measures 
for  the  control  of  a  disease  about  which  they 
were  entirely  ignorant  and  utterly  indifferent, 
was  no  small  undertaking. 

We  have  since  found  these  general  condi- 
tions repeated  in  all  the  other  West  Indian 
colonies  where  we  have  taken  up  work  against 
hookworm  disease.  There  are  a  few  minor 
differences.  In  Dutch  Guiana  ten  per  cent  of 
the  population  is  Javanese,  mainly  indentured 
laborers;  in  most  of  the  northern  islands  the 
East  Indian  element  is  lacking;  and  in  cer- 
tain of  the  colonies  the  free  population  is  found 
more  in  isolated  rural  homes  than  in  strings  of 
villages.  Elsewhere  than  in  British  Guiana  we 
have  undertaken  the  indentured  labor  as  well 
as  the  free  population. 


METHOD    OF    ATTACKING    THE    DISEASE  25 

In  the  experimental  campaign  in  Peter's 
Hall  district  the  original  plan  of  operation 
underwent  rapid  and  radical  changes  in  the 
course  of  our  contact  with  actual  conditions: 
the  area  of  operation  was  considerably  reduced, 
and  efforts  within  the  smaller  area  were  inten- 
sified. Satisfactory  progress  soon  gave  evi- 
dence of  the  wisdom  of  these  changes,  and 
subsequent  experience  with  the  method  thus 
evolved  has  fully  justified  expectations  and 
has  led  to  its  being  adopted  as  the  exclusive 
type  of  work  for  the  West  Indies.  To  inaugu- 
rate and  conduct  a  campaign  by  this  method 
it  is  desirable  that  a  definite  line  of  procedure 
should  be  followed,  which  will  be  described 
step  by  step  in  subsequent  pages. 


Ill 

SELECTION  OF  AREA  OF  OPERATION 

7.  Size  of  Area.  The  temperament  of  the 
majority  of  the  people  in  the  West  Indian 
colonies  is  such  that  their  interest  soon  wanes, 
even  in  an  effort  which  looks  to  their  improve- 
ment and  benefit.  In  this  respect  they  proba- 
bly do  not  widely  differ  from  people  living  in 
other  areas  in  the  tropics.  Furthermore,  a 
large  proportion  are  without  permanent  places 
of  abode  and  move  about  from  locality  to 
locality.  These  two  conditions  suggest  the 
desirability  of  concentrating  the  efforts  of  a 
unit  of  working  force  on  a  comparatively  small 
population,  of  waging  a  rapid  and  aggressive 
campaign,  and  of  bringing  the  campaign  to  a 
close  before  the  people  lose  interest  or  before 
removals  and  additions  to  the  population  seri- 
ously invalidate  the  original  census. 

The  size  of  the  area  will  largely  be  deter- 
mined by  the  size  of  the  unit  of  working  force, 
but  if  the  unit  of  working  force  described  on 
page  37  is  accepted,^  experience  indicates 
that  it  is  best  to  select  an  area  with  a  popula- 
tion   sufficient    to   give    each    nurse    from   one 

^  One  medical  director  in  charge,  two  clerks,  four  microscopists, 
twelve  nurses,  and  one  or  two  low-salaried  helpers  or  caretakers. 

26 


SELECTION   OF   AREA   OF    OPERATION  2/ 

hundred  fifty  to  two  hundred  cases  to  treat. 
Thus,  with  twelve  nurses  in  the  working  force, 
the  area  selected  would  include  about  2,400 
infected  persons.  In  the  West  Indies,  where 
the  average  rate  of  infection  has  been  found  to 
be  65  per  cent,  this  has  meant  that  the  average 
area  has  had  a  population  of  about  3,600. 
Usually  the  campaigns  are  preceded  by  survey 
work,  which  enables  an  estimate  to  be  made 
of  the  degree  of  infection  prevailing  throughout 
the  territory  to  be  covered. 

The  size  of  the  area  which  will  supply  the 
desired  population  will,  of  course,  vary  in  ac- 
cordance with  the  density  of  population.  In 
sparsely  settled  sections,  owing  to  the  distances 
to  be  covered  by  the  nurses  in  visiting  their 
patients,  the  selection  of  a  smaller  population 
than  that  named  may  be  advantageous,  while 
in  densely  populated  sections  or  in  villages  a 
larger  population  may  be  handled. 

8.  Rate  of  Handling  the  Population.  The 
progress  made  by  a  unit  of  force  in  handling  a 
given  population  is  indicated  by  figures  com- 
piled in  the  work  in  Trinidad  and  in  British 
Guiana.  In  Trinidad,  in  a  campaign  which 
covered  the  six  quarters  from  July  i,  1915,  to 
December  31,  1916,  and  in  which  a  working 
unit  of  about  the  standard  size  was  engaged, 
the  following  averages  per  quarter  were  obtained : 


28  INTERNATIONAL   HEALTH    BOARD 

Table  I  —  Average  Number  of  Persons  Enumerated  in 
Census,  Examined,  Found  Infected,  Given 
First  Treatment,  and  Cured  per  Quarter  in 
Trinidad,  British  West  Indies  —  July  i, 
1915,  to  December  31,  1916 

Census 2,754 

Examined 2,615 

Found  Infected Ij96i 

Given  First  Treatment Ij7I2 

Cured 1,283 

In  British  Guiana  during  the  quarter  ending 
December  31,  1916,  the  following  statistics 
were  compiled: 

Table  II  —  Number  of  Persons  Enumerated  in  Census, 
Examined,  Found  Infected,  Given  First 
Treatment,  and  Cured  in  British  Guiana 
during  Quarter  ending  December  31,  1916 

Census 7>796 

Examined 7j47I 

Found  Infected 4>i74 

Given  First  Treatment 35641 

Cured 2,233 

There  were  1,293  patients  remaining  under 
treatment  at  the  close  of  this  quarter,  so  that 
the  campaign  was  likely  to  continue  for  six 
weeks  or  two  months  longer  until  they  were 
cured.  Five  microscopists  and  twenty-one 
nurses  were  included  in  the  working  staff,  but 
the  difficulties  experienced  by  the  medical 
director  in  keeping  in  intimate  touch  with  the 


SELECTION  OF  AREA  OF  OPERATION       Zg 

details  of  the  work  of  so  large  a  force  led  to  a 
reduction  in  the  number  of  nurses  and  micros- 
copists  to  normal  proportions. 

9.  Duration  of  Work  in  Area.  An  examina- 
tion of  the  figures  given  above  indicates  that 
approximately  three  months  are  required  for 
a  unit  of  force  such  as  is  recommended,  operat- 
ing under  average  conditions,  to  complete  work 
in  an  area  which  includes  from  1,800  to  2,400 
infected  persons. 

ID.  Division  of  Area  into  Nurses'  Districts. 
After  an  area  of  operation  has  been  selected, 
it  is  divided  into  nurses'  districts,  each  con- 
taining approximately  the  same  number  of 
infected  persons,  with  such  variations  as  the 
density  of  population  and  the  consequent  dis- 
tances to  be  traveled  by  the  nurses  may  indi- 
cate. A  nurse  is  held  responsible  for  every 
detail  of  the  work  in  his  district. 

II.  Consolidation  of  Nurses' Districts.  Near 
the  conclusion  of  the  period  of  treatment,  when 
the  total  number  of  cases  remaining  uncured 
in  several  nurses'  districts  combined  has  been 
reduced  to  one  hundred  fifty  or  two  hundred, 
these  several  districts  are  put  in  charge  of  one 
nurse,  who  continues  to  administer  treatment 
until  all  of  these  cases  have  been  cured.  The 
nurses  thus  released  from  their  old  districts 
are  transferred  to  others  within  a  new  area  of 


30  INTERNATIONAL   HEALTH    BOARD 

operation.  This  new  area  usually  adjoins  the 
old.  By  following  such  a  plan  of  consolida- 
tion, the  entire  force,  both  in  the  field  and  in 
the  oflftce,  keeps  working  at  full  capacity  and 
the  per  capita  cost  of  the  work  is  materially 
reduced. 


IV 

PUBLICITY  AND   EDUCATIONAL 
MEASURES 

12.  Education  the  Primary  Aim  of  an  In- 
tensive Campaign.  Although  the  intensive 
method  has  been  defined  as  an  attempt  to 
approximate  the  complete  relief  and  control  of 
hookworm  disease  within  a  given  area,  the 
whole  work  is  essentially  educational:  it  is 
teaching  the  people  by  practical  demonstra- 
tion. Among  the  natives  in  many  tropical 
countries,  the  story  must  be  presented  in  direct 
and  concrete  terms.  Here  the  medical  directors 
rely  upon  word  of  mouth;  and  as  they  tell  the 
story  they  illustrate  its  details  by  lantern  slides, 
photographs,  and  objects.  They  use  typical 
cases  as  object  lessons;  they  point  out  the 
gross  clinical  symptoms,  which  the  people  soon 
learn  to  recognize;  they  get  specimens  of  the 
patients'  stools  and  exhibit  the  eggs  of  the 
parasite  under  the  microscope;  they  show  the 
parasites  that  have  been  expelled  by  the  treat- 
ment administered;  and  by  means  of  the 
microscope  they  exhibit  the  living,  squirming 
embryos  that  live  by  teeming  thousands  in 
the  soil  that  has  been  befouled  by  an  infected 
person  and  that  are  ready  to  infect  any  person 

31 


32  INTERNATIONAL   HEALTH    BOARD 

with  whose  bare  skin  they  come  into  contact. 
The  recovery  that  follows  treatment  and  cure 
tells  its  own  story,  both  to  the  patient  and  to 
his  friends  and  neighbors.  The  disease  thus 
lends  itself  so  readily  to  simple  demonstration 
that  the  people  —  even  native  populations  of 
tropical  countries  —  easily  understand  its  whole 
story.  They  learn  to  recognize  hookworm  dis- 
ease by  its  clinical  picture;  they  have  seen 
the  parasite  that  causes  it  and  the  eggs  by 
which  infection  is  demonstrated;  and  they 
see  how  the  infection  is  spread  and  how  it  may 
be  prevented.  As  a  result  of  this  educational 
work,  the  people  co-operate  helpfully,  in  both 
the  work  of  treatment  and  that  of  prevention.^ 

13.  Purpose  of  Educational  Work.  The 
publicity  and  educational  work  begins  imme- 
diately after  the  area  of  operation  has  been 
selected,  and  is  continuous  throughout  the 
campaign.  The  people  within  the  selected  area 
must  be  informed  about  the  disease  and  be 
interested  in  it  to  such  a  degree  that  they  will 
voluntarily  submit  themselves  for  examination, 
and  be  willing  to  take  treatment  if  found  in- 
fected. In  addition,  they  should  be  taught 
the  facts  concerning  the  transmission  of  hook- 
worm   disease   from    individual    to    individual 


^  See    First   Annual    Report,    International    Health    Board,    pages 
38-39- 


PUBLICITY  AND    EDUCATIONAL   MEASURES  33 

through  soil  pollution,  and  the  necessity  of 
each  household  providing  itself  with  a  latrine 
of  proper  type,  so  that  the  use  of  this  latrine 
by  every  member  of  the  household  may  stop 
the  further  spread  of  the  disease.  In  educating 
the  people  on  these  points,  a  favorable  oppor- 
tunity is  afforded  for  valuable  lessons  on  the 
prevention  of  disease  in  general.  This  oppor- 
tunity is  not  overlooked:  every  possible  influ- 
ence is  brought  to  bear;  and  while  the  means 
used  vary  somewhat  with  locality  and  coun- 
try, certain  lines  of  effort,  mentioned  below, 
are  common  to  all. 

14.  Lectures.  On  the  opening  of  activities 
in  a  new  area,  it  has  been  the  practice  to  arrange 
for  the  delivery,  at  some  convenient  gathering 
place,  of  an  evening  lecture  illustrated  with 
stereopticon  slides.  To  this  lecture  the  govern- 
ment officials  are  especially  invited,  and  par- 
ticular effort  is  made  to  have  present  as  many 
of  them  as  possible.  Village  officials,  clergymen, 
schoolmasters,  heads  of  societies,  health  officers, 
members  of  mission  boards  and  of  clubs,  local 
representatives  of  the  press,  and  officials  of 
planters'  or  agricultural  organizations,  are  also 
urged  to  attend.  In  addition  an  invitation  to 
the  general  public  is  widely  circulated. 

The  lecture  is  delivered  by  the  medical  di- 
rector —  if  need  be  with  the  aid  of  an  inter- 


34  INTERNATIONAL   HEALTH    BOARD 

preter  —  and  includes  not  only  a  discussion 
of  hookworm  disease,  but  an  explanation  of  the 
origin  of  the  activities  to  be  undertaken  against 
it,  the  purpose  of  these  activities,  the  sources 
of  the  funds  to  be  expended  in  the  work,  the 
necessity  for  the  co-operation  of  the  people,  the 
benefits  to  be  derived  from  such  co-operation, 
• —  individually  and  collectively,  —  and  the  im- 
portance of  sanitation  under  government  super- 
vision. Expressions  from  prominent  men  in 
the  audience  are  cordially  invited.  If  possible, 
arrangements  are  made  for  a  representative  of 
the  government  to  preside  at  this  meeting. 
Every  effort  at  this  and  at  all  subsequent  stages 
is  made  to  identify  the  work  with  the  central 
and  local  government  agencies. 

As  the  work  in  the  area  proceeds,  other  less 
formal  lectures  are  delivered  to  schools  and 
societies,  or  wherever  a  sufficient  number  of 
people  can  be  gathered  together. 

15.  Distribution  of  Literature.  The  distri- 
bution of  literature  dealing  with  hookworm 
disease,  its  detection,  treatment,  cure,  and 
prevention,  prepared  in  language  simple  enough 
to  be  intelligible  to  the  people,  is  of  undoubted 
value  and  should  not  be  neglected.  Often,  be- 
cause several  different  languages  are  spoken  in 
the  area,  these  pamphlets  and  posters  have  to 
be  printed  in  a  number  of  tongues.     Literature 


PUBLICITY   AND    EDUCATIONAL   MEASURES  35 

especially  prepared  for  use  by  local  teachers  in 
instructing  native  children  concerning  hook- 
worm disease  and  other  prevailing  diseases,  as 
well  as  concerning  the  dangers  of  soil  pollution, 
is  of  paramount  importance.  Experience  has 
shown  that  the  average  schoolmaster  is  more 
than  willing  to  use  this  literature  and  thus  to 
lend  his  aid  and  influence  to  the  work. 

16.  The  Press.  The  local  press  gives  valu- 
able voluntary  support  by  publishing  at  inter- 
vals, with  favorable  comments,  reports  giving 
various  details  of  the  progress  of  the  work. 

17.  Microscopic  Demonstrations.  Micro- 
scopic demonstrations  of  the  presence  of  ova 
and  larvae  in  feces  are  useful  as  a  means  of 
convincing  the  doubtful  and  of  securing  their 
co-operation.  These  demonstrations  are  held 
at  the  laboratory  or  in  the  homes  of  the  people. 
The  confidence  and  support  not  only  of  the 
professional  class  but  of  intelligent  classes  gen- 
erally, are  gained  by  welcoming  them  to  the 
laboratory  and  by  inviting  their  attention  to 
every  detail  of  the  work,  both  there  and  in 
the  field. 

18.  Nurses  as  a  Means  of  Publicity.  The 
nurses,  in  their  frequent  calls  at  the  homes 
within  the  area  to  collect  specimens  and  to 
administer   treatment,    have    many   opportuni- 


36  INTERNATIONAL   HEALTH    BOARD 

ties  to  win  the  confidence  of  the  people  and  to 
conduct  valuable  educational  work.  It  has 
been  the  practice  of  some  medical  directors  to 
give  the  nurses  a  special  course  of  instruction 
to  fit  them  fully  for  this  phase  of  their  duties. 


V 

WORKING  FORCE 

19.  Size  of  Working  Staff.  Experience 
gained  in  the  campaigns  conducted  in  the 
West  Indian  colonies  during  the  past  four 
years  has  shown  that  a  working  staff  of  the 
following  size  is,  all  in  all,  the  most  efficient 
unit  for  the  relief  and  control  of  hookworm 
disease  by  the  intensive  method:  one  medical 
director  in  charge,  two  clerks,  four  micros- 
copists,  twelve  nurses,  and  one  or  two  low- 
salaried  helpers  or  caretakers. 

There  is  a  definite  ratio  between  the  different 
elements  of  this  unit  of  force.  Only  three  of 
the  microscopists  work  with  microscopes;  the 
fourth  is  chief  microscopist,  verifying  and  re- 
cording the  work  of  the  others  and  instructing 
them  in  their  duties.  Under  average  condi- 
tions it  requires  four  nurses  actively  engaged 
in  their  routine  work  in  the  field  to  supply 
sufficient  specimens  to  occupy  the  time  of  one 
microscopist.  A  force  of  the  size  suggested  will 
reach  so  many  people,  and  cover  so  extensive 
an  area,  that  the  full  time  of  one  medical  di- 
rector will  be  needed  to  supervise  it.  For  this 
reason  it  is  considered  as  large  a  force  as  can 
be  effectively  managed  by  one  director.     If  it 

37 


38  INTERNATIONAL   HEALTH    BOARD 

is  desirable  to  handle  the  population  of  a  coun- 
try more  rapidly  than  is  possible  with  a  force 
of  this  size,  it  is  better  to  increase  the  number 
of  units  than  to  alter  materially  the  proportions 
between  the  different  groups  of  employes  com- 
posing each  unit. 

The  maximum  number  of  employes  in  one 
unit  of  working  force  was  reached  in  one  of 
the  West  Indian  colonies  during  the  first  half 
of  1916.  Here  the  force  consisted  of  one  medi- 
cal director,  four  clerks,  five  microscopists, 
twelve  nurses,  thirty-one  assistant  nurses,  and 
three  caretakers,  —  a  total  of  fifty-six  persons. 
This  force  was  maintained  at  a  monthly  cost 
of  ^1,346.21.  Not  all  of  these  fifty-six  persons 
were  engaged  in  the  work  conducted  from  the 
central  office,  small  dispensaries  having  been 
established  at  various  points,  where  micros- 
copists, nurses,  and  their  assistants  carried 
on  their  duties  with  occasional  visits  from  the 
director. 

The  results  of  this  experiment,  and  of  other 
experiments  similar  but  of  smaller  scope,  show 
very  clearly  that  it  is  not  advisable  to  enlarge 
the  force  and  to  increase  the  area  of  operation 
to  undue  dimensions  if  the  campaign  is  to  re- 
tain those  characteristics  which  justify  the  term 
"intensive."  Rather,  the  object  should  be  to 
organize  a  well-balanced  force  and  to  concen- 


WORKING   FORCE  39 

trate  its  efforts  on  a  comparatively  small  area 
and  small  population,  in  order  to  accomplish 
the  end  quickly  and  pass  to  a  new  area.  Such 
a  course  permits  the  medical  director  to  super- 
vise every  detail  of  the  work,  and  to  have  inti- 
mate daily  knowledge  of  every  important  occur- 
rence. This  detailed  supervision  by  the  di- 
rector is  very  essential,  since  in  the  West  Indies 
he  must  operate  in  every  instance  with  a  force 
locally  recruited,  whose  members  have  had  no 
other  special  training  for  the  work  than  that 
which  he  is  able  to  give  them;  and  this  train- 
ing can  be  made  effective  only  in  so  far  as  the 
medical  director  can  supervise  their  work. 

20.  Branch  Offices  in  Area.  The  establish- 
ment of  branch  offices  at  various  points  through- 
out the  area,  for  doing  microscopic  work  or  as 
a  rendezvous  for  nurses  engaged  in  giving  treat- 
ment, has  not  led  to  efficiency  in  any  instance. 
It  seems  rather  to  invite  the  forces  stationed 
at  these  remote  points,  free  from  the  surveil- 
lance of  the  medical  director,  to  follow  their 
own  devices.  Certainly,  if  the  results  of  mi- 
croscopic work  are  to  have  more  than  doubtful 
value,  that  work  should  be  done  at  the  central 
laboratory  under  the  personal  supervision  of 
the  director. 

21.  Duties  of  the  Medical  Director.  The 
medical    director    is    the    administrative    and 


40  INTERNATIONAL   HEALTH    BOARD 

medical  head  of  the  field  unit.  He  directs  the 
work  while  it  is  in  progress,  and  is  responsible 
for  the  results  accomplished.  He  must  have 
control  of  his  force,  and  must  be  in  position  to 
apply  discipline  or  reward  merit  without  delay 
and  without  the  intervention  of  a  third  party. 
To  command  his  force  and  secure  efl[icient 
work,  he  must  have  the  power  to  terminate, 
with  legal  notice,  the  services  of  any  undesir- 
able member.  Every  subordinate  in  the  West 
Indies  is  therefore  asked  to  sign  an  agreement 
in  which  he  places  himself  under  the  authority 
of  the  medical  director,  and  offers  to  discharge, 
to  the  best  of  his  ability,  whatever  duties  may 
be  assigned  to  him.  A  copy  of  this  agreement 
appears  in  the  appendix,  page  172.^ 

22.  Relation  of  Medical  Director  to  Govern- 
ment. Inasmuch  as  the  intensive  campaign  is 
intended  as  a  demonstration  of  the  possibili- 
ties of  a  direct  and  definite  attack  upon  a  pre- 
vailing disease,  both  the  organization  of  the 
force  and  the  direction  of  its  activities  must 
be  considered  as  only  a  temporary  first  step 
toward  the  establishment  of  permanent  agen- 
cies which  shall  in  time  apply  similar  or  better 


^  In  this  connection  it  may  be  stated  that  the  practice  of  using  gov- 
ernment employes  as  subordinates  in  the  force,  by  having  them  "sec- 
onded" from  government  departments  to  this  special  service,  is  open 
to  objection,  both  theoretically  and  from  experience. 


WORKING   FORCE  4I 

methods  to  the  control  of  all  diseases.  The 
most  successful  work,  then,  is  that  which 
brings  to  the  public  such  keen  realization  of 
benefit  that  it  is  prepared  not  only  to  co-operate 
in  further  and  more  comprehensive  undertak- 
ings of  similar  nature,  but  to  insist  that  per- 
manent agencies  be  established  to  continue 
such  work.  With  this  end  in  view,  the  medical 
director  should  be  stimulated  to  secure  the 
highest  degree  of  efficiency  from  his  force,  so 
that  with  and  through  its  members  he  may 
render  the  greatest  possible  service  and  leave 
behind  him  when  his  work  is  finished,  as  a 
legacy  to  the  government  which  has  welcomed 
his  coming,  a  public  converted  to  modern  ideas 
of  sanitation  and  the  prevention  of  disease. 

23.  Relationship  of  Medical  Director  to  the 
People.  The  proper  relationship  between  the 
medical  director  and  the  people  is  one  which 
can  be  neither  established  nor  maintained  by 
proxy.  Early  in  the  work  the  medical  director 
visits  all  parts  of  the  area  and  becomes  per- 
sonally acquainted  with  the  people.  At  all 
times  he  is  accessible  to  them,  and  shows  sym- 
pathetic interest  in  their  attitude  and  view- 
point regarding  the  work.  Before  treatment 
is  given,  he  calls  at  the  homes  of  all  persons 
found  infected,  to  ascertain  whether  or  not 
treatment  can  safely  be  administered  to  them. 


42  INTERNATIONAL   HEALTH    BOARD 

and  also  to  prescribe  the  proper  dosage.  This 
personal  service  and  attention  is  a  very  impor- 
tant factor  in  securing  the  co-operation  of  the 
patients  in  taking  treatment  until  cured. 

24.  Duties  of  Clerical  Force.  The  clerical 
force  is  needed  to  record  statistics  and  to  for- 
mulate reports.  This  work  is  done  under  the 
immediate  supervision  of  the  medical  director. 
At  least  one  of  the  clerks  should  be  a  typist. 
Inasmuch  as  the  nurses  work  on  Sundays  and 
have  Wednesdays  off,  they  leave  their  treat- 
ment books  in  the  office  on  Wednesdays,  when 
the  clerks  transfer  from  the  nurses'  books  to 
the  case-record  book  retained  in  the  office,  all 
data  which  have  not  previously  been  entered 
in  the  case-record  book.^ 

25.  Duties  of  Chief  Clerk.  The  chief  clerk 
is  in  charge  of  the  stock  of  drugs  and  specimen 
containers,  and  issues  supplies  of  these  items 
to  the  nurses  as  required.  Each  nurse  is 
charged  with  the  supplies  issued  to  him,  and 
is  provided  with  a  locker  in  which  to  store 
them.  On  Wednesdays,  when  the  nurses  are 
off  duty,  the  amount  of  supplies  used  by  each 
nurse,  as  shown  in  his  reports,  is  deducted  from 
the  list  of  supplies  issued  to  him,  and  the  con- 

^  For  a  discussion  of  the  methods  used  in  recording  and  reporting 
information,  as  well  as  for  samples  of  the  various  forms  used,  see  pages 
123  to  164. 


WORKING    FORCE  43 

tents  of  his  locker  are  checked  with  the  re- 
mainder. In  this  way  it  is  possible  to  account 
for  all  supplies  issued.  After  checking  the 
reports  of  the  nurses,  the  chief  clerk  makes  out 
and  posts  in  the  office  a  sheet  showing:  (a)  the 
number  of  treatments  given  by  each  nurse 
during  the  past  week;  and  (b)  the  total  num- 
ber of  treatments  to  date  given  by  each  nurse 
in  his  district.  The  names  of  the  nurses  appear 
on  this  sheet  in  the  order  of  their  merit  and 
efficiency  as  shown  by  the  number  of  treat- 
ments they  have  given.  This  stimulates  inter- 
est and  a  wholesome  spirit  of  rivalry,  and  leads 
to  more  efficient  service. 

26.  Duties  of  Chief  Microscopist.  The  chief 
microscopist  is  held  responsible  for  all  the  work 
of  the  microscopic  department.  In  addition 
to  instructing  new  men,  he  verifies  and  records 
all  findings  of  his  assistants,  and  checks  up 
their  daily  reports.  He  receives  the  specimens 
brought  in  by  each  nurse,  gives  the  nurse  a 
receipt  for  them,  and  reports  to  the  medical 
director  the  failure  of  any  nurse  to  get  speci- 
mens at  the  proper  time  for  first  examination 
or  for  re-examination.  It  is  his  special  duty 
to  see  that  the  nurses  are  informed  promptly 
of  the  results  of  re-examination,  so  that  there 
may  be  no  delay  in  the  course  of  treatment. 
He  is  held  responsible  for  the  scientific  equip- 


44  INTERNATIONAL   HEALTH    BOARD 

ment  of  the  laboratory,  and  for  maintaining 
the  methods  and  technique  prescribed  by  the 
medical  director. 

27.  Duties  of  Microscopists.  The  micros- 
copists  examine,  according  to  the  technique 
and  laboratory  procedure  prescribed  by  the 
medical  director,  all  specimens  submitted  to 
them  by  the  chief  microscopist.  They  aid  the 
chief  microscopist  in  keeping  a  record  of  all 
specimens  coming  into  the  laboratory  for  ex- 
amination and  in  preparing  the  daily  and 
weekly  reports  of  the  work  of  the  department, 
and  they  perform  any  other  duties  which  may 
be  assigned  them  by  the  medical  director  or  the 
chief  microscopist.  In  the  early  part  of  a 
campaign  they  often  help  in  taking  the  census, 
and  when  not  otherwise  engaged  assist  in  the 
clerical  work.  On  Wednesday  of  each  week, 
in  the  absence  of  the  nurses  from  duty,  the 
microscopists  finish  any  laboratory  work  which 
may  be  waiting,  prepare  a  week's  supply  of 
magnesium  sulphate  solution,  and  clean  their 
laboratory  equipment. 

28.  Selection  of  Microscopists.  In  choosing 
microscopists,  preference  is  given  to  men  be- 
tween twenty  and  twenty-five  years  of  age. 
Probably  the  best  class  available  in  the  West 
Indies  consists  of  natives  of  East  Indian  par- 
entage, who,  having  profited  by  the  educational 


WORKING    FORCE  45 

advantages  of  the  local  schools  and  institutions, 
are  above  the  average  in  intelligence.  They 
are  quick  to  learn,  and  accurate  and  rapid  in 
their  work.  Members  of  the  black  or  colored 
races  are  also  employed. 

29.  Training  of  Micro scopists.  It  is  seldom 
possible  to  secure  men  for  microscopists  who 
have  had  previous  laboratory  experience.  The 
medical  director  therefore  has  to  train  his  force 
of  microscopists  when  the  work  is  begun  in 
each  country.  Since  the  technique  and  labo- 
ratory procedure  are  not  elaborate  and  lend 
themselves  particularly  well  to  the  training 
process,  the  men  soon  acquire  the  necessary 
skill  to  distinguish  the  ova  of  various  intestinal 
parasites.  As  early  as  practicable,  the  most 
intelligent  and  most  skilful  of  the  microscopists 
is  made  chief  microscopist,  and  later,  when  he 
has  fully  proved  his  skill  and  fitness,  the  train- 
ing of  new  men  engaged  to  examine  specimens 
devolves  upon  him. 

30.  Duties  of  Nurses.  As  stated  on  page 
26,  the  area  of  operation  is  divided  into  dis- 
tricts, each  of  which  is  placed  in  charge  of  a 
nurse.  This  nurse  takes  a  census  of  the  people 
in  his  district,  recording  in  his  census  book 
such  facts  as  are  required.  While  taking  the 
census  he  delivers  to  each  person  a  tin  container 
properly  marked  with  his  name,  age,  and  house 


46  INTERNATIONAL   HEALTH    BOARD 

number,  at  the  same  time  giving  directions  as 
to  how  the  specimen  of  feces  to  be  placed  in 
the  container  shall  be  prepared,  and  stating 
that  on  the  following  day  he  will  call  for  the 
specimen.  On  his  first  visit  to  each  house  the 
nurse  inspects  the  sanitary  accommodations 
and  enters  in  the  census  book  the  conditions 
found.  On  later  visits  he  collects  specimens 
and  delivers  them  to  the  laboratory  for  ex- 
amination. As  the  specimens  from  people  in 
his  district  are  examined,  he  is  informed  of  the 
results,  and  records  in  his  treatment  book  the 
names  of  all  persons  found  infected.  He  then 
calls  upon  each  of  these  persons  and  arranges 
the  day  of  the  week  upon  which  that  person 
will  take  treatment,  as  well  as  the  day  upon 
which  the  medical  director  may  call  and  ex- 
amine him.  Treatment  is  then  administered 
according  to  the  instructions  issued  by  the 
medical  director.^ 

In  work  by  the  intensive  method  it  is  re- 
quired that  each  patient  be  treated  once 
weekly,  on  the  same  day  of  the  week,  until 
cured.  To  make  this  possible  the  patient  is 
re-examined  on  the  seventh  day  after  treat- 
ment. It  is  the  duty  of  the  nurse  to  secure 
specimens  for  re-examination  seven  days  after 

^  For  a  detailed  discussion  of  the  method  of  treatment,  see  pages 
69    to   94. 


WORKING    FORCE  47 

the  second  treatment,  and  seven  days  after 
each  successive  treatment  until  the  patient 
has  been  cured.  So  few  persons  are  cured  by 
one  treatment  that  no  re-examination  is  made 
after  the  first  treatment. 

The  nurses  are  expected  to  administer  per- 
sonally every  dose  of  medicine  necessary  in 
the  treatment,  and  to  keep  in  close  touch  with 
the  patients  on  the  day  of  treatment.  They 
are  responsible  for  all  supplies  issued  to  them. 
Once  weekly  they  must  account  for  these  sup- 
plies, and  the  value  of  any  shortage  not  ex- 
plained satisfactorily  is  deducted  from  their 
wage.  They  are  required  to  make  a  daily  and 
weekly  report  of  their  activities.  Sunday  being 
a  day  of  idleness,  many  people  elect  to  take 
treatment  then.  This  requires  that  the  nurses 
work  on  Sunday,  in  consequence  of  which 
Wednesday  of  each  week  is  given  them  as  a 
rest  day. 

31.  Duties  of  Chief  Nurse.  Usually  the 
most  skilful  of  the  nurses  is  placed  in  charge 
of  his  fellow-workers.  His  principal  duties 
are:  (i)  to  visit  the  various  nurses'  districts, 
making  inquiry  of  the  people  to  ascertain  if 
the  census  has  been  properly  taken,  if  speci- 
mens are  being  obtained  from  every  individual 
at  the  proper  time,  and  if  treatments  are  being 
given  regularly  and  correctly;    (2)  to  visit  and 


48  INTERNATIONAL    HEALTH    BOARD 

attempt  to  secure  the  co-operation  of  malcon- 
tents among  the  people;  (3)  to  see  whether 
specimens  are  being  collected  for  re-examina- 
tion at  proper  intervals  after  treatment;  (4)  to 
keep  account  of  the  medicine  issued  to  each 
nurse,  and,  by  checking  off  the  total  used  at 
the  end  of  the  week,  to  ascertain  if  the  quan- 
tity remaining  is  correct;  and  (5)  to  call  to 
the  attention  of  the  medical  director  any  irreg- 
ularity, or  any  matter  requiring  his  personal 
attention.  These  duties  are  very  important 
and  for  this  reason  the  chief  nurse  should  be 
a  very  trustworthy  person. 

32.  Selection  of  Nurses.  The  nurses,  like 
the  microscopists,  are  recruited  locally.  They 
may  represent  any  one  or  several  of  the  dif- 
ferent elements  of  population.  They  are  men 
usually  older  than  those  employed  as  micros- 
copists, and  are  often  of  the  schoolmaster 
class.  Generally  they  have  had  no  previous 
experience  in  caring  for  the  sick.  They  should 
write  legibly  and  should  possess  sufficient  cleri- 
cal ability  to  enable  them  to  take  the  census 
and  to  keep  their  treatment  record  books. 
Above  all,  they  should  be  trustworthy,  for 
they  must  discharge  their  duties,  most  impor- 
tant in  nature,  in  the  field,  where  they  cannot 
be  always  under  the  eye  of  the  director. 

The  employment  of  young,  immature  nurses 


WORKING    FORCE  49 

because  they  may  be  had  at  small  salaries  is  a 
very  doubtful  economy.  To  entrust  to  any  but 
the  best  type  of  men  available  the  important 
duties  performed  by  the  nurses  is  to  endanger 
the  success  of  the  work.  The  nurses  should  be 
mature  men,  with  a  history  of  honesty  and 
faithfulness  to  duty  in  previous  services,  and 
should  be  permanent  members  of  the  force  so 
long  as  they  perform  the  duties  expected  of 
them.  The  experiment  has  been  tried  of  em- 
ploying schoolmasters  and  others  for  a  por- 
tion of  each  week,  for  a  few  hours  of  each  day, 
or  for  a  few  days  during  the  height  of  a  cam- 
paign. In  several  instances  the  results  have 
been  far  from  satisfactory.  They  are  not  under 
the  discipline  and  control  of  the  medical  di- 
rector, and  have  little  to  lose  if  their  services  are 
found  unsatisfactory.  Consequently  they  show 
only  a  selfish  interest  in  the  work. 

33.  Training  of  Nurses.  The  training  of 
the  nurses  in  the  administration  of  salts  and 
thymol  or  chenopodium  is  not  a  difficult  matter, 
as  unusual  skill  is  not  required  to  employ  these 
comparatively  safe  drugs,  and  as  a  safeguard 
against  unpleasant  accidents,  the  medical  di- 
rector is  always  near  at  hand  to  be  summoned 
in  those  rare  cases  where  disturbing  symptoms 
develop.  In  the  thousands  of  cases  treated  in 
the  West  Indian  colonies  we  have  never  had 


50  INTERNATIONAL    HEALTH    BOARD 

serious  symptoms  produced  by  thymol,  —  the 
drug  of  our  choice.  The  practice  of  our  di- 
rectors of  making  a  personal  cHnical  examination 
of  every  infected  person,  to  test  the  heart  and 
lungs  by  stethoscope  and  by  percussion,  and 
also  to  prescribe  the  proper  dose  of  thymol 
for  each,  probably  accounts  in  large  measure 
for  this  freedom  from  serious  symptoms. 

When  new  men  are  taken  into  the  nursing 
force,  the  medical  director  delivers  a  series  of 
short  lectures  to  give  them  a  practical  working 
knowledge  of  their  duties,  especially  those  con- 
cerned with  the  art  of  approaching  the  people 
and  of  gaining  their  confidence  and  co-opera- 
tion. In  addition,  these  lectures  deal  with 
the  method  of  administering  thymol,  with  its 
contraindications,  its  toxic  effects,  and  with 
the  simple  antidotes  which  ordinarily  will  re- 
lieve these  effects.  A  clear  and  non-technical 
account  of  the  life  history  of  the  hookworm, 
emphasizing  the  close  relationship  of  soil  pollu- 
tion to  the  spread  of  the  infection,  is  also  given. 
Before  a  recruit  to  the  nursing  force  is  given  a 
position  as  nurse,  with  responsibilities  of  his 
own,  he  is  required  to  spend  at  least  a  fortnight 
in  observing  the  work  of  other  nurses  in  the 
field.  1 


^  Special  instructions  issued  to  nurses  by  the  medical  director  appear 
in  the  appendix,  section  V. 


WORKING    FORCE  5 1 

34.  Duties  of  Caretakers.  The  caretakers 
are  generally  boys  or  women  who  are  employed 
to  sweep,  wash  slides,  bury  refuse,  and  run 
errands.  They  may  be  hired  at  very  moderate 
salaries. 

35.  Salaries  of  Subordinate  Employes.  In 
the  West  Indies  a  maximum  salary  of  ^50.00 
a  month  has  been  fixed  for  the  chief  clerk,  and 
a  correspondingly  lower  sum  for  his  assistants. 
The  maximum  for  the  nurses  and  microscopists 
has  been  fixed  at  ^40.00  a  month,  but  they  re- 
ceive this  only  after  a  considerable  term  of 
faithful  and  efllicient  service.  Only  a  small 
part  of  the  microscopic  and  nursing  force  in 
the  West  Indies  has  yet  reached  the  maximum 
wage.  Though  these  salaries  may  seem  small, 
it  should  be  remembered  that  conditions  in  the 
West  Indies  are  quite  different  from  those  in 
most  other  countries,  and  that  living  expenses 
are  comparatively  very  low.  The  salaries  paid 
our  em^ployes  are  above  those  which  usually 
they  could  earn  in  any  other  line  of  work,  and 
we  have  had  no  difficulty  in  hiring  men  of  the 
right  type  on  these  terms. 

36.  Allowances  for  Subordinate  Employes. 
No  subordinate  employe  is  paid  any  allowance 
for  travel,  for  sustenance  or  quarters,  or  for 
any  other  purposes.  In  all  instances  allow- 
ances for  such  items  are  reckoned  and  included 


52  INTERNATIONAL    HEALTH    BOARD 

as  part  of  the  salary.  For  a  certain  monthly 
payment  each  employe  must  render  satisfac- 
tory service,  and  must  provide  himself  at  his 
own  expense  with  a  bicycle  or  such  other  means 
of  travel  as  may  be  judged  necessary  by  the 
director.  This  arrangement  relieves  the  direc- 
tor and  the  clerical  department  of  the  necessity 
of  keeping  numerous  petty  accounts,  and  greatly 
simplifies  the  question  of  remuneration  for  the 
force. 


VI 
CENSUS  TAKING 

37.  Necessity  for  Accurate  Census.  To 
make  effective  any  plan  for  the  complete  relief 
and  control  of  hookworm  disease,  it  is  neces- 
sary to  secure  a  correct  census  which  will 
embrace  all  individuals  within  the  field  of  opera- 
tion; to  record  the  personal  history  of  each 
individual  as  to  name,  race,  sex,  and  age;  and 
to  number  or  mark  each  house,  making  this 
number  a  part  of  the  record,  so  that  every  indi- 
vidual may  be  located  at  any  time.  This  cen- 
sus is  taken  by  the  nurses.  It  is  a  decided 
economy  in  time  if  the  nurses,  when  they  are 
taking  the  census,  also  deliver  to  each  indi- 
vidual a  specimen  container  marked  with  his 
name,  age,  and  house  number,  and  request 
him  to  prepare  a  specimen  of  his  feces  which 
will  be  called  for  on  the  following  day.  A 
survey  of  latrine  conditions  at  each  home  is 
made  at  the  same  time  the  census  is  taken, 
and  is  included  as  a  part  of  the  census  report. 
By  this  means  the  sanitary  problem  of  the 
area  is  at  once  determined. 

38.  Method  of  Taking  Census.  In  carry- 
ing out  the  work  of  census  taking,  the  procedure 
has  been  to  have  the  nurses  devote  the  forenoon 

S3 


54  INTERNATIONAL   HEALTH    BOARD 

to  collecting  specimens  from  individuals  visited 
on  the  previous  day,  and  the  afternoon  to  tak- 
ing the  census  and  giving  out  containers  at 
other  homes.  As  early  as  practicable  in  the 
work,  the  nurse  is  required  to  prepare  a  map 
of  his  district  showing  by  number  the  location 
of  each  house.  When  these  local  maps  are  all 
in,  a  large  map  of  the  entire  area  of  active 
operations,  to  be  retained  for  reference  in  the 
office,  is  prepared  from  them. 

Small  books  are  prepared  for  the  use  of  the 
nurses  in  taking  the  census.  These  are  of 
such  size  and  number  that  at  the  end  of  each 
day's  work  the  book  used  on  that  day  may 
be  left  at  the  central  office  for  the  purpose  of 
transcribing  the  data  in  the  permanent  record 
book  (see  sample  page  of  census  book,  pages 
124  and  125). 


VII 
MICROSCOPIC  LABORATORY 

39.  Importance  of  Laboratory  Work.  In  a 
campaign  against  hookworm  disease  the  mi- 
croscopic laboratory  furnishes  information  which 
is  the  basis  for  every  other  phase  of  the  curative 
work.  It  is  here  that  we  discover  in  the  begin- 
ning those  who  are  infected,  and  hence,  those 
who  are  to  be  treated;  and  that  later,  at  the 
conclusion  of  the  treatments,  we  determine 
who  have  been  cured.  Work  so  important 
and  upon  which  so  much  depends  deserves  the 
utmost  care  and  attention  to  detail. 

40.  Variations  in  Microscopic  Technique.  In 
our  work  the  diagnosis  of  hookworm  infection 
is  based  upon  the  presence  of  hookworm  ova 
in  the  feces  of  the  host.  This  presence  can  be 
determined  most  readily  by  microscopic  ex- 
amination. The  methods  used  in  preparing 
the  feces  for  examination  and  the  technique  of 
examination  followed  are  therefore  important 
considerations.  Many  techniques  have  been 
devised  for  the  examination  of  feces  for 
parasitic  ova.  All  are  directed  to  the  same 
end,  but  not  all  are  equally  accurate  nor  suffi- 
ciently practicable  for  our  purposes,  which 
involve  the  examination  of  thousands  of  speci- 
mens under  conditions  often  far  from  ideal. 

ss 


56  INTERNATIONAL   HEALTH    BOARD 

Concentration  is  a  common  characteristic  of 
nearly  all  these  methods,  and  is  attained,  re- 
spectively, by  comminution  of  the  feces,  by 
the  use  of  sieves,  by  sedimentation,  centrifug- 
ing,  or  by  washing  in  water.  Before  any  method 
of  concentration  can  be  employed,  the  fecal 
mass  must  be  broken  up,  to  set  free  the  em- 
bedded and  adherent  ova,  and  water  or  some 
other  agent  must  be  added  to  obtain  fluidity. 

In  the  work  in  the  West  Indies  in  which  the 
International  Health  Board  has  participated, 
unusual  difficulties  have  had  to  be  met  in 
organizing  a  laboratory  force  and  in  selecting 
a  technique  which  would  promise  accuracy  in 
results.  It  was  necessary  to  have:  first,  a 
method  that  was  rapid  without  sacrifice  of 
accuracy,  so  that  large  numbers  of  specimens 
could  be  handled  at  a  minimum  cost;  second, 
a  technique  that  was  simple,  requiring  the 
minimum  of  skill  on  the  part  of  laboratory 
employes,  none  of  whom,  as  a  rule,  had  had 
previous  experience  or  training  in  such  work, 
and  so  had  to  be  taught  all  that  it  was  neces- 
sary for  them  to  know;  and  third,  a  procedure 
whereby  every  fecal  specimen  submitted  would 
be  so  handled  that  the  microscopic  findings 
would  be  the  result  of  the  inspection  of  two 
or  more  microscopists,  one  of  them  an  expert. 
The    last    feature    was    intended    to    eliminate 


MICROSCOPIC  LABORATORY  57 

the  element  of  error  which  always  exists  to 
greater  or  less  degree  in  individual  effort  or 
research,  and  to  place  an  effectual  check  on 
the  more  insidious  harm  often  resulting  from 
the  employment  of  careless  or  dishonest  persons. 

41.  Original  Technique  in  British  Guiana. 
In  our  first  work  in  British  Guiana  in  1914, 
our  technique  of  examinations  was  that  given 
by  Dock  and  Bass.^  It  consisted  of  the  ex- 
amination of  at  least  three  direct  smears  from 
each  specimen  on  i  x  3  inch  microscope  slides 
before  negative  findings  were  recorded.  We 
realized  that  this  method  permitted  many 
light  infections  to  escape  observation  and  we 
adopted  it  only  temporarily,  as  a  starting  point 
from  which  to  develop  a  better  technique. 

Later  the  accuracy  of  this  direct  smear 
method  as  compared  with  that  attained  by 
our  present  method  of  examination  was  put 
to  test  by  certain  experiments  undertaken  in 
British  Guiana  ^  and  Trinidad.^  In  the  two 
colonies  a  total  of  2,134  specimens  was  examined 
first  by  one  method  and  then  by  the  other; 
700  specimens    in    British    Guiana    and    1,434 


1  "Hookworm  Disease,"  Dock  and  Bass,  pp.  159-161. 

2  Report  of  Dr.  F.  E.  Field,  Supervising  Medical  Officer  of  Anky- 
lostomiasis Campaign  in  British  Guiana,  1914-1916,  I.H.B. 

^  Report  of  Dr.  B.  E.  Washburn,  Medical  Officer  in  Charge  of  An- 
kylostomiasis Campaign  in  Trinidad,  1915-1916,  I.H.B. 


58  INTERNATIONAL   HEALTH    BOARD 

in  Trinidad.  In  the  test  made  in  British 
Guiana,  five  direct  smears  on  i  x  2  inch  slides 
were  required  before  a  negative  finding  was 
accepted ;  in  Trinidad,  three  smears  on  2  x  3 
inch  sHdes  were  required.  The  result  of  the 
2,134  examinations  was  to  reveal  1,049  posi- 
tive cases,  or  an  infection  of  49.2  per  cent.  A 
second  examination  was  then  made  of  the  same 
specimens  by  our  present  technique,  which  will 
be  discussed  in  detail  later  and  which  calls  for 
careful  centrifuging  of  an  emulsion  of  the  feces 
in  water  as  an  important  step.  The  result  of 
this  second  examination  was  to  show  1,277 
cases  positive,  or  59.8  per  cent.  Thus,  there 
was  a  difi^erence  of  10.6  in  the  percentages  of 
infection  found  by  the  two  methods,  which, 
as  an  element  of  error  chargeable  to  the  direct 
smear  method,  indicates  that  its  exclusive  use 
is  not  desirable.^ 

In  the  three  years  which  have  elapsed  since 
our  first  organized  operations  in  British  Gui- 
ana, we  have  extended  our  work  to  Trinidad, 
Grenada,  St.  Vincent,  St.  Lucia,  Antigua,  Bar- 
bados, Tobago,  Dutch  Guiana,  and  the  Cay- 
man Islands;  have  examined  thousands  of 
persons;  and  have  made  a  constant  effort  to 
develop  a  microscopic  technique  which  would 

^  See  table  on  page  64  showing  results  obtained  in  Trinidad  in 
examining  the  specimens  of  1,434  persons  by  the  two  methods. 


MICROSCOPIC    LABORATORY  59 

meet  every  demand.  What  measure  of  success 
has  rewarded  this  effort  may  be  determined 
by  a  perusal  of  the  following  pages,  in  which 
the  details  of  our  laboratory  work  are  set  forth. 

42.  Standard  Technique  of  Intensive  Method. 
All  specimens  collected  are  brought  to  the  lab- 
oratory by  the  nurses.  When  a  nurse  brings 
in  specimens  from  his  district,  the  chief  micros- 
copist  receives,  counts,  and  checks  them  with 
the  census  list  presented  by  the  nurse,  and 
acknowledges  their  receipt  by  initialing  the 
nurse's  list.  Until  they  are  to  be  examined, 
the  specimens  from  each  nurse's  district  are 
kept  on  separate  shelves  in  a  case  prepared 
for  this  purpose.  When  the  specimens  are 
ready  for  examination,  the  chief  microscopist 
takes  those  from  a  single  district,  and,  arrang- 
ing them  on  his  table  or  desk, —  which  should 
be  high  enough  for  him  to  stand  while  at  work, 
—  records  on  the  microscopic  report  sheet  ^ 
the  data  appearing  on  the  top  of  each  speci- 
men container.  The  chief  microscopist  has  on 
his  table  microscope  slides,  flat  wooden  tooth- 
picks, and  a  dropper-bottle  containing  water. 
The  assistant  microscopists  are  seated  at  three 
small  tables  just  behind  him.  There  should 
be  sufficient  space  between  the  tables  of  the 
microscopists   to   allow   the    chief  microscopist 

^  See  form,  pages  132-133. 


6o  INTERNATIONAL    HEALTH    BOARD 

to  pass  freely  in  his  inspections  to  verify  the 
findings  of  his  assistants. 

The  chief  microscopist  takes  the  first  speci- 
men recorded  on  his  sheet  and  prepares  three 
smears  from  it,  each  on  a  2  x  3  inch  slide,  using 
water  as  a  diluent  and  spreading  the  smear 
evenly  with  a  toothpick,  which  he  discards 
when  the  third  slide  is  prepared.  No  cover 
glasses  are  used.  He  then  gives  one  of  the 
smears  to  each  of  his  assistants,  who  at  once 
examines  it  through  his  microscope.  While 
the  assistants  are  doing  this  the  chief  micros- 
copist proceeds  to  prepare  three  smears  in 
the  same  way  from  the  next  specimen  on  his 
list.  If,  during  the  examination  of  the  slides, 
a  microscopist  discovers  a  parasite  egg  or  larva, 
he  attracts  the  attention  of  the  chief  micros- 
copist, who  examines,  verifies,  and  records 
the  finding  without  announcing  to  the  other 
microscopists  what  it  is.  If  the  first  finding  is 
a  hookworm  egg  or  larva,  the  chief  micros- 
copist allows  this  assistant  and  the  others  to 
continue  their  search  only  until  he  has  prepared 
three  smears  from  the  next  specimen.  But  if 
the  finding  is  other  than  a  hookworm  egg  or 
larva,  the  examination  continues  until  the 
possibilities  of  the  three  smears  are  exhausted. 

If  all  three  smears  are  found  negative  to 
hookworm  infection,  the  specimen  from  which 


MICROSCOPIC    LABORATORY  6 1 

they  were  prepared  is  set  aside  for  centrifuging 
later.  In  determining  the  length  of  time  to 
be  devoted  to  the  examination  of  each  speci- 
men, it  should  be  kept  in  mind  that  this  first 
examination  need  not  be  exhaustive,  because  it 
is  not  final  except  for  positive  results;  it  is 
mainly  to  eliminate  specimens  representing 
heavy  infection,  which,  because  of  the  numer- 
ous ova  present,  do  not  need  to  be  centrifuged 
for  an  accurate  diagnosis  to  be  made. 

43.  Advantages  of  Standard  Technique.  The 
method  set  forth  above  has  several  advantages 
worthy  of  mention:  first,  as  already  pointed 
out,  each  finding  being  verified  by  the  chief 
microscopist  before  being  recorded,  individual 
error  is  eliminated  and  our  results  are  protected 
from  harm  at  the  hands  of  careless,  unskilled, 
or  dishonest  employes;  second,  in  the  interval 
of  several  minutes  which  must  occur  between 
the  first  finding  and  the  end  of  the  period 
allotted  to  the  examination  of  each  specimen, 
the  three  microscopists  are  busily  engaged  in 
further  examination  of  their  respective  slides, 
thus  increasing  the  likelihood  of  corroborative 
findings  and  rendering  more  conclusive  our 
data  regarding  the  incidence  of  intestinal  para- 
sites other  than  the  hookworm;  and,  third,  by 
giving  each  microscopist  a  distinguishing  num- 
ber or  letter  and   by  using  this   instead  of  a 


62  INTERNATIONAL   HEALTH    BOARD 

mark  to  Indicate  positive  findings  on  the  mi- 
croscopic report  sheet,  it  is  easy  to  compute  at 
the  end  of  the  day  the  total  positive  findings 
of  each  microscopist,  and  thus  arrive  at  the 
relative  efficiency  of  the  men. 

44.  Modified  Technique  to  Facilitate  Proc- 
ess of  Examination.  If  the  above  method 
should  prove  too  slow,  as  it  may  In  some  stages 
of  the  campaign  when  large  numbers  of  speci- 
mens are  coming  in  daily,  the  following  modi- 
fication, which  will  permit  more  rapid  work 
and  at  the  same  time  will  not  affect  the  ac- 
curacy of  the  results  as  to  hookworm  infection, 
is  recommended. 

The  chief  microscopist.  Instead  of  preparing 
three  smears  from  one  specimen,  each  smear  to 
be  examined  by  a  different  microscopist,  pre- 
pares one  smear  from  each  of  three  specimens, 
giving  a  smear  to  each  microscopist  for  exami- 
nation. In  first  examinations  in  localities  where 
there  is  an  average  rate  of  infection  correspond- 
ing to  that  in  the  West  Indies,  at  least  two  of 
these  three  slides  will  be  immediately  found 
positive  to  hookworm;  and  these  findings,  on 
being  verified  by  the  chief  microscopist,  can 
be  recorded  and  the  examination  of  other 
specimens  be  undertaken  at  once.  It  is  pro- 
posed In  this  modification  that  the  chief  mi- 
croscopist   shall    verify   every   positive    finding 


MICROSCOPIC    LABORATORY  63 

as  before,  but  it  is  not  proposed  that  all  three 
microscopists  shall  each  examine  a  smear  from 
every  specimen.  By  this  modified  method  the 
data  secured  regarding  the  incidence  of  parasi- 
tic infections  other  than  hookworm  are  not  so 
conclusive  as  when  the  original  procedure  is 
followed. 

In  all  instances  in  the  first  examination  of 
each  person  —  that  is,  in  examinations  before 
the  administration  of  any  treatment  —  at  least 
two  negative  smears  are  considered  necessary 
to  determine  the  need  of  centrifuging  a  speci- 
men. By  far  the  greater  number  of  positive 
findings  are  made  on  the  first]  smear  examined 
before  centrifuging.  A  few,  however,  are  made 
on  the  second  smear.  Hence,  by  examining 
two  smears  from  each  specimen  we  are  sure 
to  reduce  to  the  minimum  the  number  of  speci- 
mens to  be  carried  through  the  more  compli- 
cated and  more  time-consuming  process  of 
centrifuging. 

45.  Average  Findings  on  Successive  Slides 
Examined.  The  following  table  shows  in  detail 
the  average  number  of  positive  findings  on  each 
slide  examined  with  the  technique  here  set 
forth : 


64  INTERNATIONAL   HEALTH    BOARD 

Table  III  —  Results  Obtained  on  Each  Smear  Before  and 
after  Centrifuging,  in  Examining  Speci- 
mens from   1,434  Persons  in  Trinidad. 

(Note:  To  diagnose  the  specimens  submitted  by  these   1,434  P^f" 
sons,  4,614  separate  microscopic  examinations  were  required.) 

Per  cent 
Examined    Positive     Positive     Negative 
Before  centrifuging 

First  smear  1434  609  42.4  825 

Second  smear  825  132  9.2  693 


After  centrifuging 

First  smear 

693 

109 

7.6 

584 

Second  smear 

584 

45 

3-2 

539 

Third  smear 

539 

0 

0 

539 

Total 

895 

62.4 

46.  Preparation  of  Specimens  for  the  Cen- 
trifuge. When  twenty  or  more  specimens  have 
been  found  negative  in  the  first  examination, 
they  are  prepared  for  the  centrifuge.  The  cen- 
trifuge used  is  a  special  machine  suppHed  by 
the  Bausch  and  Lomb  Optical  Co.,  of  Roches- 
ter, New  York,  U.S.A. ^  It  is  hand-driven,  with 
two  speeds,  and  has  a  Stewart  panhead  carry- 
ing twenty  tubes.  The  tubes,  of  glass,  are 
open  at  both  ends,  but  are  closed  with  corks 
when  the  machine  is  in  use. 

The  method  of  preparing  specimens  for  cen- 
trifuging is  as  follows: 

^  For  description,  see  page  176. 


MICROSCOPIC    LABORATORY  65 

(i)  On  a  heavy  piece  of  cardboard  14x16 
inches  in  size,  preferably  with  rough  or  matte 
surface,  twenty  z"  squares  are  ruled  and  num- 
bered from  one  to  twenty.  If  the  upper  sur- 
face of  the  cardboard  can  be  rendered  water- 
proof by  the  application  of  a  coat  of  varnish 
or  oil,  it  can  then  be  cleaned  after  use  by  wip- 
ing with  an  antiseptic  solution. 

(2)  Twenty  of  the  specimens  to  be  centri- 
fuged  are  arranged  on  this  chart,  one  in  each 
square.  The  number  of  the  square  in  which 
the  specimen  is  placed  becomes  the  centrifuge 
number  of  that  specimen  and  is  so  recorded  on 
the  microscopic  sheet.  Beginning  with  speci- 
men No.  I,  the  following  steps  are  taken  in 
preparing  the  specimens  for  centrifuging: 

{a)  The  specimen  as  it  rests  in  the  tin  con- 
tainer is  thoroughly  stirred  with  a  wooden 
toothpick  to  secure  a  uniform  distribution  of 
ova  in  the  fecal  mass.  When  the  specimen  is 
too  dry  or  too  firm  for  this  to  be  accomplished 
satisfactorily,  a  small  quantity  of  water  may 
be  added. 

(^)  Small  particles  of  feces  are  lifted  with  a 
wooden  toothpick  from  a  number  of  places  in 
the  specimen  and  placed  in  a  flat-bottom  glass 
vial.  The  quantity  of  feces  used  should  be 
from  4  to  5  grams.  To  this  should  be  added 
ten  or  more  times  its  bulk  of  water.    The  water 


66  INTERNATIONAL   HEALTH    BOARD 

and  feces  are  then  stirred  and  agitated  together 
until  an  emulsion  is  formed. 

(c)  This  emulsion  is  then  poured  into  a  cen- 
trifuge tube  through  a  glass  or  special  paper 
funnel,  in  which  are  placed  two  or  three  layers 
of  gauze.  The  purpose  of  the  gauze  is  to  re- 
move the  larger  particles  from  the  emulsion. 
The  clips  holding  the  tubes  in  the  panhead  of 
the  centrifuge  are  numbered  from  one  to  twenty. 
The  centrifuge  tube  containing  the  emulsion 
from  specimen  No.  i  on  the  chart  is  placed  in 
clip  No.  I  in  the  centrifuge,  No.  2  in  clip  No.  2, 
and  so  on.  When  all  twenty  of  the  tubes  are 
in  position,  the  top  of  the  panhead  is  screwed 
on.  The  handle  is  attached  first  to  the  low  and 
then  to  the  high  speed  shaft,  until  the  desired 
rate  of  revolutions  is  attained.  With  the  cen- 
trifuge described,  the  length  of  time  necessary 
to  throw  most  of  the  eggs  suspended  in  the 
emulsion  to  the  outer  end  of  the  tube  and  de- 
posit them  on  the  cork,  is  two  or  three  min- 
utes. The  time,  of  course,  varies  somewhat 
with  the  thickness  or  density  of  the  emulsion. 
When  the  process  of  centrifuging  is  complete, 
the  tubes,  beginning  with  No.  i,  are  taken  out 
of  the  panhead,  the  cork  in  the  inner  end  of 
each  tube  is  removed,  and  the  liquid  portion 
is  carefully  poured  off.  Afterwards  the  outer 
cork  is   removed,   and   from  the   debris  which 


MICROSCOPIC  LABORATORY  67 

is  found  deposited  on  it,  three  slides  are  pre- 
pared and  examined  by  the  method  previously 
explained. 

47.  Technique  of  Examination  Following 
Treatment.  As  the  intensive  method  aims  at 
writing  "cured"  after  the  name  of  every  in- 
fected individual  in  the  area  of  operation, 
re-examination  after  treatment,  to  ascertain 
whether  or  not  a  cure  has  been  effected,  is  an 
important  step  and  deserves  special  considera- 
tion. It  is  in  re-examinations,  where  the  num- 
ber of  worms  in  the  intestinal  canal  has  been 
reduced  by  treatment  and  where  purgation 
incident  to  the  treatment  has  swept  out  any 
accumulation  of  ova,  that  exceptional  care 
must  be  taken  to  guard  against  misleading 
negative  findings,  and  it  is  in  this  phase  of  the 
laboratory  work  that  the  use  of  the  centrifuge 
is  most  helpful.  As  the  first  and  each  succes- 
sive treatment  reduces  the  number  of  worms 
in  the  intestinal  canal  and  hence  the  proportion 
of  ova  in  the  fecal  specimens,  the  number  of 
positive  findings  possible  without  the  use  of  a 
centrifuge  is  correspondingly  lowered.  Hence, 
after  two  treatments  have  been  administered, 
it  is  a  waste  of  time  to  examine  more  than  one 
smear  from  each  specimen  before  centrifuging, 
while  some  of  the  directors  dispense  with  all 
direct    smear    examinations    after    two    treat- 


68  INTERNATIONAL    HEALTH    BOARD 

ments  and  make  centrifuging  the  first  step  of 
all  re-examinations.  So  few  cases  of  hookworm 
infection  are  cured  with  one  treatment  that 
no  re-examinations  are  made  until  a  sufficient 
interval  has  elapsed  after  the  second  treatment. 
48.  Number  of  Specimens  Examined  Daily. 
A  laboratory  with  four  skilled  microscopists 
—  that  is,  a  chief  microscopist  and  three  assist- 
ants —  should  handle  from  two  hundred  to 
three  hundred  specimens  daily,  according  to 
the  percentage  and  severity  c^  infection.  Where 
the  rate  of  infection  is  low  and  the  disease 
mild  in  form,  the  proportion  of  specimens  re- 
quiring centrifuging  is  higher  and  progress  is 
correspondingly  slower. 


VIII 
TREATMENT 

49.  Thymol  Preferred  as  Anthelmintic.  Al- 
though tests  of  other  drugs  have  been  made  in 
the  work  against  hookworm  disease  in  the  West 
Indies,  thymol  remains  the  drug  of  our  choice. 
Two  plans  of  administering  it  have  been  tried, 
—  the  daily-dose,  and  the  intensive,  or  weekly- 
dose,  methods. 

50.  Daily-dose  Method  of  Administering 
Thymol.  This  method  has  been  successfully 
used  by  Dr.  J.  E.  A.  Ferguson,  District  Medical 
Officer,  in  treating  indentured  labor  on  the 
sugar  estates  of  Peter's  Hall  district,  British 
Guiana.  It  requires  that  the  patient  be  given 
a  small  dose  of  thymol  daily  except  Sunday 
until  cured.  The  dose  of  thymol  for  the  adult 
is  ten  grains,  and  for  children  proportionately 
smaller.  No  purgation  and  no  modification  of 
diet  or  habits  is  necessary  except  abstinence 
from  alcoholics  for  a  few  hours  after  taking  the 
thymol. 

In  our  experiment  with  this  method,  we 
treated  1,876  cases  out  of  a  total  of  1,918  found 
infected  in  a  population  of  3,207.  Thymol 
distributors  visited  the  infected  persons  six 
days  in  the  week  and  administered  the  daily 
dose  of  thymol.     It  was  not  found  difficult  to 

69 


70        INTERNATIONAL  HEALTH  BOARD 

induce  most  of  the  patients  to  begin  treatment. 
In  fact,  since  the  examination  and  treatment 
were  free,  many  were  eagerly  responsive  to 
the  idea  of  "getting  something  for  nothing/' 
and  all  seemed  to  covet  the  "certificates  of 
health"  which  were  issued  to  those  who  were  not 
infected  with  hookworms,  or  which  were  prom- 
ised to  those  who,  if  infected,  would  persist 
in  being  treated  until  cured.  The  fact  that 
this  method  of  treatment  did  not  require  the 
patients  to  make  any  sacrifice  in  diet  or  habits 
was  a  persuasive  talking-point  in  inducing  the 
infected  to  begin  treatment,  but  this  advantage 
was  more  than  lost  when  it  was  learned  that 
thymol  was  to  be  given  them  daily  for  months. 

Our  experience  with  this  method  continued 
for  nine  months,  at  the  end  of  which  the  rate 
of  infection  in  the  area  where  the  plan  was  used 
had  been  reduced  from  69  to  31  per  cent.  To 
accomplish  this  reduction,  148,821  doses  of 
thymol  were  given.  The  amount  of  thymol 
necessary  for  a  cure  in  individual  cases  ranged 
from  250  to  2,000  grains. 

It  was  from  the  prolongation  of  treatment 
that  most  of  our  difficulties  with  this  method 
arose:  a  considerable  number  became  tired  of 
the  daily  dose  and  were  inclined  to  abandon 
treatment,  the  improvement  in  physical  con- 
dition being  so  slow  that  often  it  was  not  suffi- 


TREATMENT  7 1 

ciently  apparent  to  encourage  them  to  continue. 
During  the  nine-months'  period,  unavoidable 
circumstances  —  such  as  absence  from  home, 
intercurrent  illness,  etc.  —  caused  frequent  in- 
terruptions in  the  course  of  treatment,  and 
since  the  efficiency  of  this  method  seems  to 
depend  somewhat  upon  its  regularity,  this 
added  to  the  difficulties.  Also,  the  rather  elab- 
.  orate  force  required  for  the  distribution  of 
daily  doses  of  thymol  to  a  large  population, 
the  great  prolongation  of  the  course  of  treat- 
ment, and  the  large  amount  of  thymol  neces- 
sary to  cure  the  average  individual,  placed  the 
per  capita  cost  too  high  for  the  method  ever 
to  be  used  extensively  except  possibly  where 
the  persons  to  be  treated  are  under  strict  con- 
trol, as  in  certain  public  institutions,  or,  as 
is  the  case  in  treating  indentured  labor,  where 
a  force  already  in  existence  for  other  purposes 
may  be  employed  to  distribute  and  administer 
thymol. 

51.  Intensive,  or  Weekly-dose,  Method  of 
Administering  Thymol.  This  is  the  method 
used  almost  exclusively  throughout  the  West 
Indian  colonies.  It  provides  that  the  patient 
be  given  a  dose  of  thymol  on  one  day  of  each 
week  until  he  has  been  cured.  The  dose  is 
based  upon  sixty  grains  as  the  maximum  for 
an  adult,  and  is  preceded  and  followed  by  an 


72  INTERNATIONAL   HEALTH    BOARD 

active  saline  purgative,  the  patient  being  re- 
quired to  abstain  from  food  for  at  least  eighteen 
hours  during  the  treatment. 

When  the  medical  director  visits  the  infected 
people  in  their  homes  before  they  are  treated, 
he  subjects  each  of  them  to  a  thoracic  exami- 
nation with  the  stethoscope  and  by  percussion, 
and  observes  their  clinical  aspects.  The  infor- 
mation gained  by  this  examination  enables  him 
to  prescribe  the  proper  course  of  treatment  and 
dosage  for  each  individual  and  to  eliminate 
those  medically  unfit  for  treatment. 

52.  The  Medically  Unfit  for  Treatment.  Per- 
sons medically  unfit  for  treatment  include  those 
suffering  from  acute  diseases,  such  as  malaria 
(febrile  stage),  fevers  of  any  type,  diarrhea, 
dysentery,  gastritis,  etc.;  those  having  chronic 
dysentery  or  diarrhea,  organic  cardiac  or  renal 
disease,  pulmonary  tuberculosis  beyond  the 
incipient  stage,  or  general  anasarca;  those  who 
are  extremely  weak  or  feeble  from  old  age  or 
from  other  cause;  and  pregnant  women,  or 
women  with  serious  hemorrhagic  diseases  of  the 
uterus.  Patients  having  these  complications 
should  not  be  treated  for  hookworm  disease, 
except  possibly  under  hospital  conditions. 

53.  Directions  for  Taking  Thymol.  The  fol- 
lowing directions  are  given  to  each  patient  to 
be  followed  in  taking  treatment: 


TREATMENT  73 

(i)  At  5  or  6  P.M.  on  the  day  preceding 
the  treatment  take  a  cathartic  dose  of  sulphate 
of  magnesia.  No  supper  should  be  eaten.  The 
saline  should  thoroughly  empty  the  alimentary 
canal. 

(2)  Remain  in  bed  the  following  morning 
without  food,  and  at  6  a.m.  take  one-half  of 
the  thymol.    At  8  a.m.  take  the  remainder. 

(3)  Take  a  cathartic  dose  of  sulphate  of 
magnesia  at  11  a.m.  This  should  be  repeated 
if  a  thorough  movement  of  the  bowels  is  not 
secured  within  two  hours. 

(4)  No  food  should  be  taken  until  after  the 
bowels  have  moved  thoroughly,  and  then  no 
greasy  foods  or  milk  should  be  taken,  or  alco- 
holic drinks  indulged  in. 

(5)  The  usual  diet  and  habits  may  be  resumed 
on  the  day  following  the  treatment. 

(6)  If  a  feeling  of  weakness  or  dizziness  arises 
during  treatment,  take  one-half  cup  of  strong 
black  coffee  without  sugar  or  milk. 

(7)  Careful  examination  of  the  dejecta  from 
the  second  dose  of  sulphate  of  magnesia  will 
show  the  dead  worms. 

There  is  a  scientific  reason  behind  each  step 
of  the  treatment  as  detailed  by  these  directions, 
which  must  be  evident  to  the  mind  of  the  medi- 
cal man  familiar  with  the  disease.  Since  hook- 
worm  is    a   disease    which   will    not   yield    to 


74  INTERNATIONAL   HEALTH    BOARD 

haphazard  medication,  some  cases  proving  obsti- 
nate under  any  method  of  treatment,  and  since 
thymol  is  a  drug  which  must  be  given  under 
certain  restrictions  in  order  to  be  safe  and 
efficient,  it  is  well  to  have  definite  directions 
to  follow  in  its  administration. 

54.  Interval  between  Treatment  with  Thy- 
mol and  Re- examination.  Early  in  the  dispen- 
sary work  in  the  Southern  States  the  plan  of 
giving  thymol  treatment  every  week  was 
adopted,  and  in  the  main  has  been  adhered  to 
since.  This  practice  requires  that  all  re-exami- 
nations be  made  on  the  seventh  day  after 
treatment.  This  interval  of  seven  days  be- 
tween treatment  and  re-examination  is  probably 
not  of  sufficient  length  to  place  above  sus- 
picion all  negative  findings  so  recorded,  inas- 
much as  the  female  worms  not  expelled  by  the 
treatment  are  to  greater  or  less  degree  subjected 
to  the  toxic  effects  of  the  thymol,  and  cease 
egg-bearing  for  an  undetermined  length  of  time. 
Hence,  absence  of  ova  from  fecal  specimens 
collected  from  a  patient  too  recently  treated  is 
not  conclusive  evidence  of  cure. 

To  ascertain  the  proper  interval  between 
treatment  and  re-examination  where  thymol  is 
used,  several  of  our  medical  directors  have  ex- 
amined a  series  of  cases  at  different  intervals 
after  treatment.    These  investigations  have  es- 


TREATMENT  75 

tablished  the  belief  that  very  few  cases  found 
negative  on  the  seventh  day  after  treatment 
with  thymol  will  be  found  positive  if  re-ex- 
amined at  the  end  of  a  longer  interval.  The 
fact  that  a  small  percentage  will,  however,  has 
led  certain  of  the  medical  directors  to  obtain 
a  second  specimen  for  re-examination  seven  days 
after  the  first  negative  specimen  was  obtained, 
and  to  pronounce  no  patient  cured  until  at 
least  two  specimens  —  one  obtained  seven  and 
the  other  fourteen  days  after  the  latest  treat- 
ment —  have  been  found  free  of  ova. 

55.  Number  of  Thymol  Treatments  Neces- 
sary to  Cure.  Several  of  these  courses  of  thy- 
mol given  at  weekly  intervals  are  usually  neces- 
sary for  a  cure.  Where  the  alimentary  canal 
is  thoroughly  cleared  out  by  salines  before  the 
administration  of  the  thymol,  and  the  patients 
abstain  from  food  and  receive  the  second  dose 
of  saline  at  the  proper  time,  we  have  a  right  to 
expect  50  per  cent  of  the  cases  to  be  cured  with 
two  treatments.  In  our  four  years'  experience 
in  the  West  Indies  any  marked  decrease  in  this 
percentage  has  invariably  meant  either  faulty 
preparation  of  the  thymol  or  its  improper  ad- 
ministration. This  means  that  about  half  our 
cases  are  cured  with  two  treatments,  or  in  eight 
days  after  the  first  examination.  Only  a  small 
percentage  require  more  than  three  treatments. 


76  INTERNATIONAL   HEALTH    BOARD 

Almost  any  person  who  is  convinced  that  he 
harbors  hookworms  in  his  body  will  readily 
consent  to  give  one  day  of  each  week  for  two 
or  three  weeks  to  be  cured  of  this  malady. 

56.  Is  Thymol  a  Dangerous  Drug?  It  has 
often  been  stated  that  the  above  mentioned 
dose  of  thymol  is  dangerous.  In  reply  to  this, 
I  point  to  the  fact  that  more  than  a  million 
maximum  doses  of  thymol  have  been  adminis- 
tered in  the  United  States,  and  several  hundred 
thousand  similar  doses  in  our  work  in  the  for- 
eign fields,  to  persons  of  every  age,  color,  race, 
and  physical  condition,  and  that  many  of  these 
treatments  early  in  our  work  were  taken  by 
the  patients  in  their  own  homes  without  super- 
vision from  nurse  or  physician,  and  yet  with- 
out fatality  or  serious  physical  disturbance  of 
any  kind,  except  in  a  very  limited  number  of 
cases  where  the  patients  indulged  in  alcoholic 
drinks  or  failed  to  follow  directions  in  some 
other  important  detail.  It  is  extremely  prob- 
able that  in  a  large  number  of  cases  the  thymol 
was  incorrectly  taken,  for  many  of  the  people 
were  illiterate  and  otherwise  densely  ignorant. 
I  fancy  there  are  few  drugs  in  the  pharma- 
copoeia which  could  stand  so  severe  a  test  with 
so  few  instances  of  serious  toxic  symptoms. 

57.  Preparation  of  Thymol  for  Administra- 
tion.    Observations  were  made   by   Dr.    B.    E. 


TREATMENT  'J'J 

Washburn,  Medical  Officer  in  Charge  of  the 
Ankylostomiasis  Campaign  in  Trinidad,  Brit- 
ish West  Indies,  on  the  use  of  thymol  alone 
and  in  combination  with  different  proportions 
of  sugar  of  milk.  The  results  of  this  investiga- 
tion were  as  follows: 

(i)  Three  hundred  and  twenty-five  patients  were  treated 
with  pure  thymol,  finely  powdered  and  encapsu- 
lated; 41,  or  12.6  per  cent,  were  cured  with  two 
treatments. 

(2)  Three  hundred  and  fifty  cases  were  treated  with  a 

supply  of  thymol  already  mixed  with  sugar  of 
milk  and  encapsulated  by  the  manufacturer.  The 
thymol  was  not  so  finely  powdered,  and  was  com- 
bined with  the  following  proportions  of  milk  sugar: 

10  grains  thymol  to  z\  grains  milk  sugar; 
5  grains  thymol  to  5  grains  milk  sugar; 
2\  grains  thymol  to  z\  grains  milk  sugar. 

Most  of  the  treatments  consisted  of  doses  of  the  first 
proportion,  i.e.,  10  grains  thymol  to  z\  grains  milk 
sugar.  Of  the  350  cases  treated  with  this  mixture, 
'j(i,  or  21.7  per  cent,  were  cured  with  two  treatments. 

(3)  One   thousand  one  hundred   and  twelve  cases  were 

treated  with  finely  powdered  thymol  mixed  with 
equal  parts  of  milk  sugar;  546,  or  49.1  per  cent,  of 
these  cases  were  cured  with  two  treatments. 

These  results  are  presented  in  summary  form  below: 


78  INTERNATIONAL   HEALTH    BOARD 

Per  cent  of  cures 
Agent  used  with  two  treatments 

Finely  powdered  thymol 12.6 

Thymol  with   less  than  equal  quantity  of 

milk  sugar 21.7 

Thymol  with  equal  quantity  of  milk  sugar. .      49. 1 

The  dosage  of  thymol  and  the  method  of  admin- 
istration were  the  same  in  every  instance.  All 
medicine  was  administered  by  trained  attend- 
ants, who  kept  the  patients  under  observation 
during  treatment.  Although  Dr.  Washburn's 
experiments  did  not  deal  with  numbers  suffi- 
ciently large  to  make  his  results  conclusive,  his 
findings  have  nevertheless  been  fully  substan- 
tiated by  other  experiments  of  a  similar  nature 
since  made  by  the  medical  directors  of  cam- 
paigns in  other  colonies,  those  of  Dr.  F.  E.  Field 
in  British  Guiana  deserving  special  mention. 

Evidently  thymol,  when  combined  with  an 
equal  quantity  of  milk  sugar  and  the  two 
thoroughly  triturated  together,  is  much  more 
effective  than  when  given  alone  or  in  a  granular 
state.  This  is  likely  due  to  the  fact  that  in  this 
combination  the  thymol  remains  in  a  state  of 
fine  division  until  liberated  in  the  stomach, 
and  thus,  being  more  uniformly  distributed 
throughout  the  bowel  contents,  comes  more 
intimately  into  contact  with  a  larger  proportion 
of  the  worms  in  the  bowel. 


TREATMENT  79 

58.  Toxic  Effects  of  Thymol.  Thymol  Is  an 
irritant  to  the  mucous  Hnings  of  the  stomach 
and  intestine,  but  seemingly  only  to  a  very 
slight  degree  when  those  membranes  are  nor- 
mal and  healthy.  With  acute,  sub-acute,  and 
chronic  diarrhea  and  dysentery,  and  related 
troubles,  the  use  of  thymol  is  contraindicated 
because  its  effect  upon  the  already  inflamed 
mucous  membranes  of  the  alimentary  canal  is 
to  aggravate  the  inflammatory  processes,  much 
to  the  discomfort  and  harm  of  the  patient. 

Except  in  the  case  of  a  very  few  persons  who, 
because  of  an  idiosyncrasy,  cannot  safely  take 
even  a  small  dose  of  thymol,  serious  toxic  symp- 
toms develop  from  its  use  only  when  it  passes 
into  solution  in  the  stomach  or  intestine  and  is 
absorbed  into  the  blood  current.  It  is  said  to 
be  only  slightly  soluble  in  the  normal  gastric 
and  intestinal  juices,  and  it  is  this  fact  which 
enables  us  to  give  it,  without  harm  to  the 
patient,  in  the  comparatively  large  doses  neces- 
sary to  expel  the  hookworms. 

Thymol  is  soluble  in  oils  and  fats,  and  very 
soluble  in  alcohol  and  its  dilutions.  The  pres- 
ence in  the  intestinal  canal  of  either  oils,  fats, 
or  alcohol  along  with  a  large  dose  of  thymol 
will  often,  but  not  invariably,  lead  to  the  de- 
velopment of  toxic  symptoms.  Furthermore, 
if  the  dose  of  thymol  used  in  the  treatment  of 


8o        INTERNATIONAL  HEALTH  BOARD 

hookworm  disease  is  allowed  to  remain  in  the 
alimentary  canal  indefinitely,  a  more  or  less 
gradual  absorption  of  the  drug  may  take  place, 
and  the  patient  will  develop  toxic  symptoms. 

The  toxic  effects  of  thymol  may  be  classed 
under  two  heads,  according  to  the  degree  of 
intoxication:  minor  symptoms,  and  serious 
symptoms. 

59.  Minor  Symptoms  of  Thymol  Poisoning. 
The  minor  symptoms  include: 

(j)  Muscular  weakness  and  lassitude.  Most 
often  these  are  due  to  the  patient's  abstaining 
from  food  during  the  treatment  and  to  the  effect 
of  the  cathartic  doses  of  magnesium  sulphate. 
Usually,  except  in  the  very  young  and  very  old, 
these  symptoms,  when  manifested  alone,  are 
negligible. 

(2)  Vertigo,  or  giddiness.  This  is  usually 
attributed  to  the  absorption  of  the  thymol  into 
the  blood  current,  with  its  resultant  effect  upon 
the  cerebral  centers.  A  certain  percentage  of 
the  patients  treated  with  thymol  experience 
slight  vertigo  during  the  treatment,  which  is 
relieved  immediately  when  the  patient  assumes 
a  reclining  position,  and  disappears  entirely 
when  the  cathartic,  which  should  always  follow 
the  administration  of  thymol,  has  emptied  the 
intestinal  canal. 

(5)  Gastric  and  intestinal  irritation.     This  is 


TREATMENT  8 1 

usually  manifested  by  a  feeling  of  heat  or  burn- 
ing in  the  esophagus  and  stomach,  and  by 
colicky  pains  in  the  abdomen.  These  symp- 
toms are  most  often  of  a  transient  nature,  not 
requiring  any  special  effort  at  relief.  In  a 
small  percentage  of  cases,  when  the  gastric 
irritation  does  persist,  relief  often  may  be  had 
by  giving  the  patient  a  glass  of  soda  water  (one 
teaspoonful  of  baking  soda  in  a  goblet  of  water). 
If  this  does  not  accomplish  the  desired  result 
and  the  distress  of  the  patient  is  severe,  one  or 
more  tablespoonfuls  of  milk  of  bismuth,  diluted 
with  twice  its  quantity  of  water,  will  afford 
relief. 

(4)  Nausea  sometimes  follows  the  administra- 
tion of  thymol.  This  is  especially  true  where  the 
preparatory  dose  of  magnesium  sulphate  is  still 
active  when  the  thymol  is  given.  By  keeping 
the  patient  quiet  and  in  a  recumbent  position, 
vomiting  rarely  occurs  to  the  extent  of  inter- 
fering with  the  course  of  treatment. 

60.  Serious  Symptoms  of  Thymol  Poisoning. 
When  serious  symptoms  appear,  they  manifest 
themselves  in  several  or  all  of  the  following 
phenomena: 

Vertigo  has  been  mentioned  already  as  a 
minor  symptom,  but  in  proportion  as  it  in- 
creases in  degree,  accompanied  by  other  dis- 
turbing   symptoms,    it    indicates    further    and 


82  INTERNATIONAL   HEALTH    BOARD 

increasingly  dangerous  absorption  of  thymol 
into  the  blood  current.  It  is  usually  accom- 
panied by  headache,  by  tinnitus,  and  by  dis- 
turbances of  vision.  At  first  the  pulse  rate  is 
slowed,  but  later  it  may  become  rapid,  thready, 
and  weak.  Respiration  is  slowed,  and  later 
may  assume  a  sighing,  or  Cheyne-Stokes,  char- 
acter. The  lips  and  finger  tips  become  blue. 
The  face  is  pale  and  anxious,  and  may  be 
bathed  in  a  clammy  sweat.  At  this  stage  there 
is  a  decided  fall  in  the  body  temperature,  and 
the  clinical  picture  is  very  similar  to  that  of 
surgical  shock  or  collapse.  The  patient  usually 
suffers  with  delirium,  and  unless  reaction  takes 
place  here,  the  cyanosis  increases,  the  circula- 
tion and  respiration  are  further  depressed,  the 
patient  passes  into  a  condition  of  complete 
coma,  and  dies. 

6i.  Treatment  of  Thymol  Poisoning.  For  the 
milder  forms  of  toxic  symptoms  —  i.e.,  muscu- 
lar weakness,  vertigo,  slight  cyanosis,  and  slow- 
ing of  pulse  rate  and  respiration,  —  either  no 
intervention  is  necessary  or  the  following  sim- 
ple measures  suffice: 

(i)  Put  the  patient  to  bed  and  give  a  cup  of 
strong,  hot  coffee  without  sugar  or  milk. 

(2)  If  possible,  empty  the  bowel  with  a  high 
enema  of  warm  water,  or  of  Senna  and  salts 
solution. 


TREATMENT  83 

(3)  If  the  enema  does  not  immediately  pro- 
duce satisfactory  results  and  relief  does  not 
immediately  follow,  give  a  full  cathartic  dose 
of  Epsom  salts,  or  of  any  other  active  saline, 
in  hot  water. 

(4)  Do  not  at  this  or  at  any  other  stage  give 
castor  oil  as  a  purgative,  or  alcoholics  by  the 
mouth  as  a  stimulant. 

In  cases  where  collapse  has  already  come  or 
seems  imminent,  resort  should  be  had  to  more 
powerful  stimulants  administered  with  a  hypo- 
dermic needle.  These  stimulants,  in  the  proba- 
ble order  of  their  usefulness  in  such  emergency, 
would  be:  Morphia,  i/6  gr.,  with  1/150  gr.  Atro- 
pine; Strychnine  nitrate,  1/30  gr. ;  Nitrogly- 
cerin, i/ioo  gr. ;  or  Digitalin,  i/ioo  gr.  (Adult 
dosage).  The  patient  should  be  wrapped  in 
blankets  and  be  kept  warm  with  hot-water 
bottles  until  reaction  takes  place.  No  effort 
should  be  spared  to  empty  the  bowel  thoroughly, 
and  by  so  doing  to  stop  further  absorption  of 
the  thymol. 

The  recovery  of  a  patient  from  even  the  more 
severe  degrees  of  thymol  poisoning  is  very 
rapid,  and  secondary  symptoms,  if  they  de- 
velop, may  be  treated  symptomatically.  Un- 
suspected organic  weakness  or  disease  may 
accentuate  any  one  or  several  of  the  above 
mentioned  symptoms.     It  should  not  be  over- 


84  INTERNATIONAL   HEALTH    BOARD 

looked,  furthermore,  that  to  thymol  are  attrib- 
uted certain  powers  as  an  abortifacient  in 
pregnancy,  and  for  this  reason  it  should  be 
given  only  under  proper  conditions  and  with 
proper  precautions  when  this  condition  exists. 

62.  Use  of  Oil  of  Chenopodium  as  an  Anthel- 
mintic. Although  in  recent  years  oil  of  cheno- 
podium has  been  growing  in  favor  as  a  remedy 
for  hookworm  disease,  the  experiments  with  this 
drug  which  have  been  made  in  the  West  Indian 
colonies  have  in  no  instance  led  to  its  general 
use.  Various  methods  have  been  recommended 
for  its  administration,  the  chief  of  which  are 
summarized  below. 

63.  Schiiffner  and  Vervoort  Method  of  Ad- 
ministering Chenopodium.  In  this  method  of 
treatment  by  chenopodium,  16  drops  of  the 
drug  are  administered  every  two  hours  for  three 
doses.  Two  hours  after  the  last  dose,  17  grams 
of  castor  oil,  with  3  grams  of  chloroform  dis- 
solved in  it,  are  administered.  It  is  said  that 
the  addition  of  the  chloroform  to  the  castor  oil 
is  not  strictly  necessary,  but  that  it  does  no 
harm  and  increases  the  percentage  of  cures. 
No  preliminary  purge  or  restrictions  in  diet 
are  required.  The  oil  of  chenopodium  may  be 
given  either  on  sugar  or  in  sealed  capsules. 
The  dosage  for  children  is  in  proportion  to 
body  weight  rather  than  to  age  by  years. 


TREATMENT  85 

64.  Weiss  Method  of  Administering  Che- 
nopodium.  Dr.  Weiss,  of  Sumatra,  states  that 
the  following  method  of  administration  is  em- 
ployed advantageously  with  the  labor  on  the 
rubber  estates  of  Sumatra: 

At  I  P.M.,  just  after  the  midday  meal,  i6 
drops  of  oil  of  chenopodium  are  administered. 
At  2  P.M.  and  again  at  3  p.m.,  similar  doses  of 
16  drops  are  given.  At  4.30  p.m.,  20  grams  of 
castor  oil  are  given,  after  which  the  laborer 
returns  to  his  quarters.  No  dietary  restric- 
tions are  practised,  nor  is  a  preliminary  purge 
given.  The  oil  of  chenopodium  is  administered 
in  capsules  freshly  prepared.  In  the  presence 
of  a  high  rate  of  infection  and  of  conditions 
which  favor  re-infection,  it  is  the  routine  prac- 
tice to  administer  this  treatment  twice  yearly 
to  all  laborers,  without  microscopic  examina- 
tion or  re-examination  except  in  certain  in- 
stances. 

65.  Method  of  Administering  Chenopodium 
Recommended  by  Uncinariasis  Commission  to 
the  Orient.  The  report  of  the  Uncinariasis 
Commission  to  the  Orient  contains  a  valuable 
contribution  to  our  knowledge  of  chenopodium 
and  its  use  in  treating  hookworm  infection. 
This  Commission  recommends  as  the  routine 
treatment  for  hookworm  disease,  1.5  centi- 
meters of  oil  of  chenopodium  divided  into  three 


86  INTERNATIONAL   HEALTH    BOARD 

equal  doses  and  administered  at  hourly  inter- 
vals, the  first  at  7,  the  second  at  8,  and 
the  third  at  9  a.m.  It  believes  in  giving  a 
light  evening  meal,  followed  by  a  purgative 
dose  of  magnesium  sulphate,  and  a  very  light 
breakfast,  consisting  of  milk  or  konje,  on  the 
morning  of  treatment.  At  11  a.m.,  two  hours 
after  the  last  dose  of  chenopodium  has  been 
taken,  a  purgative  dose  of  magnesium  sulphate 
is  again  administered.  Treatment  should  not 
be  repeated  in  less  than  ten  days.  After  con- 
siderable research  this  Commission  concluded 
that  magnesium  sulphate  is  a  safer  and  more 
efficient  purgative  to  use  with  chenopodium 
than  castor  oil,  which  had  formerly  been  so 
extensively  recommended. 

The  section  of  their  report  dealing  with  this 
subject  has  been  published  in  an  article  en- 
titled *'The  Treatment  of  Hookworm  Infec- 
tion," which  appeared  in  the  Journal  of  the 
American  Medical  Association.^  In  this  arti- 
cle the  relative  value  of  thymol  and  chenopo- 
dium, and  the  after-effects  produced  by  the 
use  of  these  drugs,  are  compared.  For  the 
benefit  of  readers  who  may  not  have  at  hand 
the  full  treatise,  which  was  based  on  a  series  of 
123  cases  treated  with  thymol  and  seventy-nine 

^  February  23,  19 18,  vol.  70,  pages  499-507.  Complete  reprints 
of  this  article  will  be  sent  to  all  interested  persons  upon  application 
to  the  New  York  office  of  the  International  Health  Board. 


TREATMENT  87 

treated  with  chenopodium,  the  following  sum- 
mary of  the  conclusions  reached  by  this  Com- 
mission is  appended: 

"It  would  appear  from  the  comparisons  given  that 
the  half  maximum  dose  (0.5  c.c.  three  times,  or  1.5  c.c.) 
of  oil  of  chenopodium  is  the  treatment  for  recommenda- 
tion as  a  routine  vermicide. 

"It  does  not  have  the  toxic  effects  of  the  full  dose, 
and  two  treatments  have  the  very  satisfactory  result  of 
removing  99  per  cent  of  all  worms  present. 

"It  has  the  additional  advantage  of  a  more  uniform 
action,  a  greater  effect  on  ancylostomes,  and  of  being 
less  unpleasant  to  take  than  thymol. 

"Thymol  shows  an  advantage  over  this  half-maximum 
dose  of  oil  of  chenopodium  in  that  the  90  grains'  dosage 
produces  a  better  result  when  single  treatments  are  com- 
pared. This  advantage  disappears,  however,  when  two 
half-maximum  treatments  of  oil  of  chenopodium  are 
given. 

"Smaller  doses  compare  unfavorably  with  a  single 
half-maximum  dose  of  oil  of  chenopodium.  A  dose  as 
large  as  90  grains  of  thymol,  if  administered  indiscrimi- 
nately throughout  the  population,  would  probably  give 
rise  to  serious  symptoms." 

66.  Interval  between  Treatment  with  Cheno- 
podium and  Re- examination.  Certain  direct- 
ors who  have  used  chenopodium  extensively 
report  that  it  inhibits  the  egg-bearing  function 
of  the  female  hookworm  much  longer  than  thy- 
mol, and  that  for  this  reason  a  minimum  inter- 
val of  fourteen  days  should  be  allowed  to  elapse 


88  INTERNATIONAL   HEALTH    BOARD 

between  the  treatment  of  a  case  with  chenopo- 
dium  and  re-examination.  We  have  seen  that 
the  Uncinariasis  Commission  to  the  Orient 
recommends  at  least  ten  days.  The  directors 
of  work  in  certain  countries  allow  a  similar 
period  to  elapse.  It  was  shown,  however,  by 
Washburn  and  by  Colwell  in  their  experiments 
with  chenopodium  in  Trinidad  and  in  Grenada, 
that  even  with  an  interval  of  fourteen  days 
between  treatment  and  re-examination,  there 
still  exists  a  very  material  element  of  error  in 
the  negative  findings. 

(i'j.  Preparation  of  Chenopodium  for  Admin- 
istration. The  fact  that  flexible  gelatin  cap- 
sules do  not  keep  well  in  tropical  climates  has 
led  to  the  practice  of  giving  oil  of  chenopodium 
on  sugar.  This  also  has  its  disadvantages. 
Recently,  the  ordinary  hard,  or  shell,  gelatin 
capsules  have  come  into  use  for  administering 
this  drug,  and  are  proving  quite  satisfactory. 
They  are  prepared  as  follows:  the  required 
number  of  minims  of  oil  of  chenopodium  is 
placed  in  the  long  end  of  the  capsule;  the  edges 
of  the  cap  portion  are  moistened  on  the  inside 
with  water,  using  a  fine  camel's-hair  brush;  the 
capsule  is  then  closed  and  the  cap  portion 
forced  firmly  down.  To  allow  the  cap  to  dry 
in  position,  the  capsules  are  placed  in  a  rack 
in  an  upright  position  for  fifteen  minutes.    Care 


TREATMENT  89 

should  be  taken  to  get  no  oil  on  the  outside  of 
the  long  end  of  the  capsule,  as  otherwise  the 
cap  will  not  adhere  properly  and  the  oil  will 
leak  out.  When  the  capsules  are  dry  they 
should  be  kept  in  an  air-tight  container,  into 
which,  for  its  drying  properties,  a  small  quan- 
tity of  lycopodium  powder  may  be  dusted. 

68.  Measurement  of  Oil  of  Chenopodium. 
Chenopodium  is  usually  measured  either  by 
the  drop  or  by  the  minim.  In  testing  the  rela- 
tionship of  the  drop  to  the  minim  we  find  that 
no  two  droppers,  even  of  apparently  the  same 
make  and  size,  give  the  same  proportion  of 
minims  to  drops  in  a  cubic  centimeter.  The 
slightest  variation  in  the  calibre  of  the  tip  of 
the  dropper,  of  the  position  in  which  the  dropper 
is  held,  of  the  weight  of  the  fluid  column  in  the 
dropper  barrel,  of  the  temperature  of  the  oil, 
or  of  the  specific  gravity  of  the  oil  (which  varies 
considerably  in  different  samples),  renders  the 
drop  a  most  uncertain  quantity.  Medical 
directors  should  be  specially  cautioned  not  to 
use  the  drop  as  a  unit  of  measure. 

69.  Toxic  Effects  of  Chenopodium.  The 
writer  has  recently  had  brought  to  his  notice 
a  considerable  number  of  cases  of  chenopodium 
poisoning,  only  a  few  of  which  have  yet  ap- 
peared in  medical  literature.  These  cases, 
which  unfortunately  have  not  been  free  from 


90  INTERNATIONAL   HEALTH    BOARD 

fatalities,  have  occurred  in  the  Southern  States, 
the  West  Indian  colonies,  Panama,  Nicaragua, 
Ceylon,  Egypt,  and  Brazil.  In  nearly  every 
case  the  oil  of  chenopodium  was  adminis- 
tered by  one  of  the  accepted  methods  of  treat- 
ment and  in  less  than  the  maximum  dose  (of 
3  c.c). 

In  most  of  these  cases  the  alimentary  canal 
was  kept  as  nearly  empty  as  possible  for  the 
period  of  treatment,  by  restrictions  in  diet  and 
by  purgation;  and  magnesium  sulphate  was 
used  as  the  purgative.  This  is  significant  in 
view  of  the  following  statements  by  Salant  and 
Nelson:  ^ 

"The  toxicity  of  chenopodium  is  distinctly  increased 
in  starvation  and  is  decreased  by  feeding  oils  and  by 
feeding  a  rich  carbohydrate  diet  ..." 

"The  increased  toxicity  of  chenopodium  in  starvation 
and  its  cumulative  effect  are  important  factors,  as  shown 
in  our  experiments  in  determining  its  toxicity.  It  is 
quite  possible  that  the  reason  there  are  so  few  cases  of 
poisoning  in  the  literature  is  that  castor  oil  has  been 
administered  immediately  after  chenopodium,  which  is 
quite  likely  to  exert  an  antidotal  effect  on  the  drug." 

Attention  should  be  called,  however,  to  the 
fact  that  these  conclusions  of  Salant  and  Nel- 
son do  not  agree  with  the  experience  of  the 
Uncinariasis  Commission  to  the  Orient,  which 

^  Toxicity  of  Oil  of  Chenopodium,  by  Salant  and  Nelson,  Reprint 
from  American  Journal  of  Physiology,  Vol.  36,  No.  4. 


TREATMENT  9 1 

found  that  persons  who  had  taken  castor  oil 
"  always  showed  the  greater  number  of  cases  of 
dizziness  and  deafness,  most  of  the  cases  of 
inabihty  to  rise  and  walk  occurring  in  this 
group."  This  Commission  reported  also  that 
"dizziness  and  muscular  incoordination  were 
less  marked  with  magnesium  sulphate  than 
with  castor  oil." 

It  is  reported  that  in  Sumatra  several  hun- 
dred thousands  of  doses  of  chenopodium  have 
been  administered  by  the  method  described  on 
page  85  without  the  development  of  toxic 
symptoms.  It  is  interesting  to  note  that  this 
method  does  not  require  restrictions  in  diet; 
that  the  persons  dealt  with  normally  subsist 
on  "  a  rich,  carbohydrate  diet";  and  that  "cas- 
tor oil  is  administered  immediately  after  the 
chenopodium."  The  fact  that  the  treatment  is 
given  without  preliminary  microscopic  diagno- 
sis and  without  microscopic  re-examination  to 
ascertain  if  those  treated  have  been  cured,  how- 
ever, makes  uncertain  its  efficacy  in  curing 
the  patient,  although  it  is  said  to  cause  marked 
improvement  in  physical  condition. 

70.  Symptoms  of  Chenopodium  Poisoning. 
These  symptoms  seem  to  group  themselves 
under  two  heads:  (i)  Gastro-intestinal  symp- 
toms and  (2)  Neuro-toxic  symptoms: 

(i)  Gastro-intestinal  symptoms:  In  many  cases 


92  INTERNATIONAL   HEALTH    BOARD 

where  oil  of  chenopodium  is  administered  there 
is  evidence  of  irritation  to  the  mucous  Hning 
of  the  stomach  and  intestine,  manifested  by  a 
sensation  of  heat  or  burning  in  the  stomach 
and  by  coHcky  pains  which  may  continue  for 
several  days.  Nausea  and  vomiting  are  some- 
times present.  As  a  rule,  the  gastro-intestinal 
symptoms  are  not  severe  and  need  give  rise  to  no 
alarm,  but  in  three  cases  reported  recently  from 
one  of  the  Southern  States  these  symptoms  de- 
veloped rapidly,  violent  retching  and  purging 
occurred,  and  the  patients  collapsed  and  died, 
apparently  without  any  marked  involvement 
of  the  central  nervous  system  or  other  evidences 
of  absorption  of  the  drug. 

(2)  N euro-toxic  symptoms:  Many  patients  to 
whom  oil  of  chenopodium  has  been  given  com- 
plain in  a  few  hours  of  tingling  or  numb  sensa- 
tions in  the  extremities.  These  symptoms  may 
persist  for  several  days,  often  causing  the  pa- 
tient much  discomfort  and  uneasiness.  The 
more  severe  neuro-toxic  symptoms  —  consist- 
ing of  headache  (usually  frontal),  vertigo,  tinni- 
tus aurium,  deafness,  muscular  weakness,  mus- 
cular incoordination,  localized  muscular  spasms, 
delirium  or  mental  incoherence,  convulsions, 
and  coma  —  rarely  develop  in  less  than  from 
twenty-four  to  thirty-six  hours  after  the  drug 
has  been  taken,   and   have  been  known  to  be 


TREATMENT  93 

delayed  until  the  third  day  after  treatment. 
In  most  fatal  cases  reported,  these  symptoms 
have  developed  in  the  order  given,  the  patient 
dying  in  deep  coma  after  a  severe  convulsive 
attack. 

The  aural  phenomena  produced  by  cheno- 
podium  poisoning  are  very  constant,  and  often 
persist  for  a  long  period  after  other  symptoms 
have  subsided.  Dr.  Samuel  Seiton  of  New 
York  reported  three  cases  in  which  the  "  anom- 
alies of  audition"  were  very  marked.  He 
inferred  "that  the  medicine  had  a  somewhat 
specific  effect  on  the  middle  ear,'*  and  spoke 
of  the  vertigo  as  being  of  auditory  origin.^ 

71.  Treatment  of  Chenopodium  Poisoning. 
Salant  and  Livingston  state  that  chenopodium 
depresses  the  heart's  action,  causing  a  marked 
fall  in  blood  pressure,  and  that  it  also  depresses 
the  respiratory  centers,  with  resulting  decrease 
in  the  rate  and  amplitude  of  respiration.  The 
character  of  its  toxic  symptoms  indicates  also 
that  it  produces  a  cerebral  congestion  and  has 
a  somewhat  selective  action  on  the  auditory 
mechanism. 

On  the  development  of  symptoms  of  poison- 
ing by  chenopodium,  a  dose  of  castor  oil  should 
be    administered    at   once,    and    should   be    re- 


^  American   Journal   Otology,   Vol.   2,    1880,  Aural   Phenomena   of 
Chenopodium   Poisoning,   S.   Seiton,   M.D. 


94  INTERNATIONAL   HEALTH    BOARD 

peated,  if  necessary,  until  the  alimentary  canal 
has  been  thoroughly  cleared.  This  first  meas- 
ure is  advisable  not  alone  because  it  clears  the 
alimentary  canal  of  the  drug  and  prevents 
further  absorption,  but  also  because  of  the 
antidotal  properties  which  are  attributed  to 
castor  oil. 

The  cardiac  symptoms  may  be  met  with 
digitalin,  preferably  administered  subcutane- 
ously.  The  convulsed  condition  often  met  with 
in  these  cases  does  not  necessarily  contraindi- 
cate  strychnia  in  small  doses  as  a  respiratory 
and  general  stimulant.  In  collapse,  the  appli- 
cation of  heat  to  the  body  and  other  restorative 
measures  may  be  employed. 

That  oil  of  chenopodium  will  ultimately 
occupy  an  important  place  as  a  vermifuge  is 
evident  to  all  who  have  used  it  for  this  purpose. 
It  is  also  evident,  and  becoming  more  so  with  in- 
creasing experience,  that  it  is  a  powerful  poison, 
often  uncertain  in  action  with  our  present 
dosage  and  methods  of  administration.  To 
render  it  safe  and  efficient  as  a  therapeutic 
agent,  more  knowledge  must  be  had  as  to  the 
proper  method  of  its  preparation,  as  to  its 
chemical  composition  and  stability,  and  as  to 
its  proper  dosage  and  method  of  administration. 


IX 

SANITARY  MEASURES   FOR 
PREVENTION 

72.  Necessity  of  Preventing  Soil  Pollution. 
As  the  whole  question  of  preventing  the  spread 
of  hookworm  disease  is  one  of  guarding  against 
the  deposit  of  ova-impregnated  feces  on  the 
surface  of  the  ground,  where  the  eggs  can  hatch 
and  develop  into  infective  larvae,  the  problem 
of  establishing  an  adequate  and  satisfactory- 
system  for  the  disposal  of  night  soil  becomes 
of  paramount  importance.  In  the  West  Indian 
colonies  this  feature  of  the  work  is  entirely  in 
the  hands  of  the  local  governments.  The 
Board  undertakes  merely  to  locate  and  to 
cure,  so  far  as  this  may  be  possible,  every  per- 
son infected  with  hookworm  disease  in  the 
areas  of  operation,  and  to  educate  all  of  the 
people  —  through  literature  and  illustrated  lec- 
tures, and  by  other  means  —  in  ideas  of  modern 
sanitation  and  disease-prevention. 

73.  How  the  Sanitary  Problem  is  Defined. 
The  sanitary  problem  of  an  area  of  operation 
is  determined  by  a  house-to-house  survey  of 
latrine  conditions,  and  the  object  in  sanitation 
has  been  accomplished  when  every  house  has 
been  provided  with  adequate  latrine  accommo- 

95 


96  INTERNATIONAL   HEALTH    BOARD 

dations  and  when  a  system  of  inspection  has 
been  established  to  guarantee  their  proper  use. 
The  sanitary  work,  which  must  be  kept  under 
a  system  of  permanent  inspection,  is  carried 
out  by  permanent  government  agencies.  Where 
no  sanitary  organization  exists,  the  intensive 
work  enables  the  government  to  undertake  a 
definite  sanitary  task  on  the  basis  of  an  insig- 
nificant outlay  and  to  develop  its  sanitary 
organization  gradually,  as  the  work  is  extended 
from  area  to  area  and  as  the  people  are  edu- 
cated to  the  point  of  giving  willing  and  intel- 
ligent co-operation.^ 

The  International  Health  Board  does  not 
undertake  to  advise  as  to  the  definite  type  of 
latrine  to  be  installed  in  these  areas  of  opera- 
tion in  the  West  Indies.  The  department  of 
health  in  each  country  is  responsible  to  its 
people  for  all  sanitary  measures  carried  out 
under  its  direction,  and  must,  therefore,  use  its 
own  judgment  as  to  the  type  of  latrine  recom- 
mended. 

74.  T5TDes  of  Latrines  to  Prevent  Soil  Con- 
tamination. In  most  instances  the  pail  or  pit 
type,  or  both,  have  been  adopted.  The  pail 
type,  under  controlled  conditions  and  with 
proper  disposal  of  the  night  soil,  is  safe;  but 
practical  experience  in  rural  communities  has 

^  See  Second  Annual  Report,  International  Health  Board,  p.  22. 


SANITARY   MEASURES    FOR   PREVENTION  97 

demonstrated  that  it  frequently  becomes  offen- 
sive and  falls  into  disuse,  and  that  extreme 
difficulty  is  experienced  in  keeping  the  boxes 
fly-proof  and  in  having  the  pails  properly 
cleaned.  Where  the  contents  of  the  pail  are 
buried  in  the  soil,  this  must  be  done  according 
to  careful  government  regulation,  else  many 
consequences  may  result  to  defeat  the  original 
purpose  of  the  effort. 

The  pit  latrine,  which  has  been  installed  in 
large  numbers  in  most  of  the  West  Indian 
colonies,  has  the  advantage  of  being  inexpen- 
sive, simple  in  construction,  and  almost  auto- 
matic in  operation.  It  has  come  into  extensive 
use  mainly  because  it  is  practical  and  the  people 
can  be  induced  to  install  and  to  use  it.  Where 
there  are  no  latrines  and  soil  pollution  is  the 
rule,  and  where  the  level  of  the  ground  water 
is  such  as  will  permit  of  serviceable  pits  being 
dug,  the  introduction  of  the  pit  latrine  is  a 
vast  improvement,  not  alone  for  controlling  the 
spread  of  hookworm  disease  but  for  reducing 
the  occurrence  of  other  excrementitious  diseases 
as  well.  One  should  remember,  however,  that 
its  use  involves  a  large  accumulation  of  excreta 
underground,  with  whatever  this  condition  im- 
plies as  to  the  danger  of  water  contamination 
by  seepage  and  underground  drainage. 

The  finding  of  a  satisfactory  method  for  the 


98  INTERNATIONAL   HEALTH    BOARD 

disposal  of  sewage  at  the  rural  home,  one 
which  the  people  may  be  brought  to  adopt  and 
to  carry  out,  and  which  will  prove  to  be  safe 
in  actual  experience  as  well  as  in  theory,  is  a 
problem  yet  to  be  solved. 


X 
PER   CAPITA  COST 

75.  Importance  of  Cost  Element.  In  con- 
sidering any  plan  or  scheme  which  contem- 
plates an  attempt  at  the  relief  or  control  of 
disease  —  or,  in  fact,  any  undertaking  of  a 
public  or  of  a  philanthropic  nature  —  the  item 
of  cost,  except  possibly  in  great  emergencies 
and  under  special  conditions,  must  receive  care- 
ful attention.  The  more  extensive  the  field  to 
be  covered,  the  more  important  becomes  this 
question  of  the  cost  of  the  enterprise. 

In  our  campaigns  in  the  West  Indies,  the 
item  of  cost  has  received  special  attention, 
since  these  efforts  are  intended  to  serve  as 
demonstrations  which,  by  proving  the  feasi- 
bility of  attaining  the  object  in  view  at  a  non- 
prohibitive cost,  will  lead  to  the  establishment 
of  permanent  agencies  to  continue  and  enlarge 
the  working  program. 

76.  How  "  Per  Capita  Cost "  is  Figured. 
When  a  given  piece  of  work  is  finished,  or  at 
the  end  of  a  calendar  year,  it  is  desirable  to 
have  some  index  of  cost  for  the  year  or  for  the 
completed  work.  This  index  is  expressed  as  the 
per  capita  cost  of  examination,  of  treatment, 
or  of  cure.    The  index  is  reached  by  the  simple 

99 


lOO  INTERNATIONAL   HEALTH    BOARD 

process  of  dividing  the  total  budgetary  expen- 
ditures of  the  campaign  by  the  number  of 
people  examined,  by  the  number  of  people 
treated,  or  by  the  number  of  people  cured,  as 
the  case  may  be.  While  this  is  called  "per 
capita  cost"  for  want  of  a  better  term,  it  is 
understood  that  it  is  not  the  actual  per  capita 
cost  of  any  one  of  these  three  features  of  the 
work,  but  only  an  index  of  cost  which  for  pur- 
poses of  comparison  is  sufficient.  From  these 
indices  one  gains  a  rather  clear  idea  of  the 
efficiency  of  a  campaign  from  the  standpoint 
of  cost.  It  should,  however,  be  kept  in  mind 
that  no  numerical  expression  can  be  given  to 
the  far-reaching  and  permanent  educational 
results  of  successful  intensive  work.  These 
results  can  find  expression  only  as  the  awakened 
interest  and  concern  of  the  people  lead  them, 
in  the  future,  to  protect  human  life  from  the 
baneful  effects  of  disease. 

'j'j.  Cost  Indices  of  West  Indies  Intensive 
Work.  The  following  table  shows  the  cost 
indices  of  the  campaigns  in  the  West  Indies  for 
the  period  of  four  years,  1914-1917.  It  should 
be  noted  that  the  tendency  has  been  downward 
in  spite  of  the  great  advance  in  the  cost  of 
medical  supplies,  of  scientific  apparatus,  and 
of  ocean  freights,  and  the  fact  that  in  several 
instances    we    are    operating    in    less    populous 


PER   CAPITA   COST 


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102       INTERNATIONAL  HEALTH  BOARD 

areas.  This  decrease  in  cost  is  probably  due 
to  improvement  in  methods,  to  greater  effi- 
ciency of  the  field  forces,  and  to  more  perfect 
co-operation  of  the  public.  It  is  obvious  that 
the  per  capita  cost  of  treatment  and  of  cure 
will  be  higher  in  those  colonies  having  light 
infection:  Antigua  exemplifies  this  fact  in  the 
accompanying  table. 


XI 

CONCLUSION 

78.  Wide  Applicability  of  Intensive  Plan. 
The  experiences  of  four  years  in  the  West  Indies 
have  demonstrated  that  the  intensive  plan  of 
work  is  feasible  under  a  great  variety  of  condi- 
tions, and  strongly  suggest  its  applicability 
under  all  conditions,  irrespective  of  race,  creed, 
occupation,  environment,  distribution  of  popu- 
lation, or  degree  of  infection.  Successful  work 
has  been  done  in  areas  where  five  different 
languages  were  spoken,  and  where  East  Indians, 
negroes,  Chinese,  Portuguese,  and  Creoles  of 
English,  Spanish,  and  French  blood,  with  a 
great  variety  of  mixed  breeds,  made  up  the 
population.  The  distribution  of  population 
has  varied  from  the  densely  inhabited  villages 
of  British  Guiana  and  Trinidad  to  the  scattered 
and  almost  inaccessible  rural  homes  of  St. 
Vincent,  where,  in  one  instance,  with  a  donkey 
to  ride,  a  nurse  could  visit  only  two  homes  in 
a  day. 

It  is  remarkable  that  in  the  sparsely  settled 
areas,  w^here  travel  and  the  distances  between 
homes  render  the  duties  of  the  nurses  so  diffi- 
cult, the  per  capita  cost  has  not  been  unduly 

increased.    When  we  consider  that  the  dangers 

103 


I04  INTERNATIONAL   HEALTH    BOARD 

of  re-infection  are,  from  natural  causes,  much 
less  in  sparsely  settled  sections  than  in  more 
densely  populated  areas,  where  it  is  corres- 
pondingly more  difficult  to  secure  adequate 
sanitary  precautions  against  soil  pollution,  it 
would  seem  reasonable  to  expect  that  in  the 
sparsely  settled  sections  total  eradication  will 
be  earlier  and  more  easily  reached. 

While  agriculture  is  the  principal  industry 
of  the  peoples  involved  in  these  campaigns, 
yet  a  variety  of  other  vocations  has  had  repre- 
sentation among  those  treated,  and  all  classes 
and  walks  of  life  are  included,  from  a  judge  of 
the  supreme  court  to  the  humble  "squatter" 
on  crown  lands. 

Certainly  climatic  conditions  have  not  fav- 
ored the  purposes  of  the  work,  for  in  all  in- 
stances we  have  operated  under  the  conditions 
common  to  tropical  countries,  which  are  recog- 
nized as  most  favorable  to  the  spread  of  hook- 
worm disease.  What  degree  of  success  we 
have  been  able  to  abtain  under  these  adverse 
and  varied  conditions  is  fully  set  forth  on 
pages  121  and  122. 

79.  Educational  Value  of  Intensive  Meas- 
ures. The  educational  value  of  a  demonstra- 
tion against  hookworm  disease  is  often  largely 
determined  by  the  thoroughness,  scientific  ac- 
curacy, and  efficiency  of  the  methods  used,  and 


CONCLUSION  105 

is  enhanced  in  proportion  as  we  more  nearly 
accomplish  complete  control  of  the  disease.  In 
any  area  of  operation  the  more  intelligent 
classes,  consisting  of  professional  men,  officials, 
clergymen,  schoolmasters,  and  plantation  own- 
ers and  managers,  whose  co-operation  is  so 
vital  to  the  success  of  the  work,  are  quite  capa- 
ble of  appreciating  the  difference  between 
thorough  and  efficient  methods  and  the  success- 
ful handling  of  the  problem,  and  the  opposite; 
and  even  the  less  intelligent  and  the  illiterate 
are  not  insensible  to  the  painstaking  care  and 
attention  given  them  individually  and  collec- 
tively in  the  effort  to  cure  and  protect  them 
from  a  disease  the  seriousness  of  which  they 
soon  come  to  understand. 

The  requirement  of  the  intensive  method 
that  every  home  be  visited  by  the  physician 
in  charge,  for  the  purpose  of  examining  the 
persons  to  be  treated  before  the  drug  is  ad- 
ministered, and  the  subsequent  weekly  visits 
of  the  nurses  to  give  treatment,  establish  a 
bond  of  sympathy  and  interest  which  in  most 
instances  continues  until  cures  are  effected. 

80.  Intensive  Method  as  Means  of  Gaining 
Good-Will  of  Populace.  One  of  the  most 
valuable  features  of  the  intensive  method  is 
that  it  gives  the  people  a  minimum  of 
inconvenience   and    annoyance   in   examination 


I06  INTERNATIONAL   HEALTH    BOARD 

and  treatment.  Everything  is  done  for  the 
patient  that  can  be  done.  His  convenience 
and  welfare  are  made  the  first  consideration. 
The  nurses  mark  and  leave  with  him  a  speci- 
men container;  they  call  for  the  specimen; 
they  report  to  him  the  result  of  the  examina- 
tion. If  he  is  infected,  the  medical  officer  calls 
upon  him,  and,  after  examination,  prescribes 
a  dose  of  thymol  and  a  course  of  treatment  to 
be  carried  out  by  the  nurse  in  the  patient's 
own  home  on  the  day  of  the  week  best  suited 
to  his  convenience.  He  is  not  asked  to  leave 
the  familiar  surroundings  of  his  home  to  make 
repeated  trips  to  some  central  point  or  hospital, 
which  often  to  his  simple  mind  is  a  place  of 
terror  and  unknown  danger.  No  essential  step 
of  the  process,  from  the  recording  of  his  name 
in  the  census  to  his  discharge  as  cured,  is  left 
to  fortuitous  circumstances  or  his  own  initia- 
tive. Although  no  compulsion  is  used,  he  is 
not  asked  or  expected  to  exercise  discretion  in 
a  matter  in  which  manifestly  he  can  have  but 
poor  discretion.  The  attitude  of  confident 
expectation  of  full  co-operation  which  the  staff 
maintains  toward  the  patient  goes  far  toward 
assuring  the  needful  co-operation. 

Dr.  Washburn,  in  commenting  upon  his  ex- 
periences with  the  intensive  method  of  cam- 
paigning   in    Trinidad,    British    West    Indies, 


CONCLUSION  107 

says:  ^  "While  the  primary  intent  of  the  inten- 
sive method  is  the  control  and  approximate 
eradication  of  hookworm  disease,  beyond  this 
is  the  purpose  that  the  results  of  this  work 
shall  demonstrate  in  a  striking  and  convincing 
way  the  possibilities  of  a  direct  and  definite 
attack  on  disease  in  general  when  both  remedial 
and  preventive  measures  are  brought  into  play. 
...  In  working  out  these  objects  [the  exami- 
nation of  all  the  people  and  the  treatment  and 
cure  of  the  infected],  many  opportunities  are 
afiPorded  for  demonstrating  to  the  people  the 
chief  factors  involved  in  the  pollution  of  the 
soil  and  in  other  health  problems.  In  fact,  the 
chief  aim  of  the  intensive  campaign  is  educa- 
tional. We  endeavor  to  give  the  people  an 
object-lesson  in  sanitation,  to  teach  them  the 
basic  facts  underlying  the  spread  of  diseases 
due  to  soil  pollution.  The  people  and  the 
government  may  be  shown  that  it  is  possible 
to  conduct  a  campaign  against  hookworm  dis- 
ease in  a  definite  area,  with  the  result  of  greatly 
lessening  the  amount  and  the  severity  of  the 
infection  and  of  measurably  approaching  the 
complete  eradication  of  the  disease. 

"We   believe    that   this    demonstration    has 
been   impressive,   and  will  lead   to   permanent 


1  Report  of  Dr.   B.   E.   Washburn,   Medical  Officer    in    charge    of 
Ankylostomiasis  Campaign  in  Trinidad,  for  the  year  1915. 


I08  INTERNATIONAL   HEALTH    BOARD 

results  because  of  the  fact  that  we  have  at- 
tempted to  do  only  one  thing,  and  have  accom- 
plished this  in  a  definite  manner.  To  teach  a 
country  the  story  of  hookworm  disease  in  all 
its  details  and  to  show  it  objectively  that  it  is 
possible  for  this  disease  to  be  effectively  dealt 
with,  is  much  better  than  to  attempt  spasmodi- 
cally to  demonstrate  the  importance  of  a  num- 
ber of  problems  of  public  health." 

The  medical  director  in  British  Guiana,  Dr. 
F.  E.  Field,  in  his  report  of  November  i8,  1914, 
in  commenting  on  the  very  successful  intensive 
campaign  completed  in  the  Peter's  Hall  dis- 
trict, says:  "All  work  recorded  in  this  report 
has  been  carried  on  without  interfering  with 
the  people's  daily  work;"  and  continues,  "It 
is  gratifying  to  report  that  the  local  authorities 
of  the  various  villages  of  Areas  A  and  B  in 
Peter's  Hall  district  have  so  thoroughly  real- 
ized the  benefits  obtained  from  the  expulsion 
of  the  hookworm  and  have  come  to  understand 
so  well  the  principles  of  re-infection  and  the 
necessity  of  preventing  it,  that  they  have  sub- 
scribed the  necessary  amount  to  maintain  a 
sanitary  inspector  to  devote  his  full  time  to 
their  district." 

In  conclusion,  then,  we  may  say  that  correct 
methods  of  conducting  the  work  inspire  con- 
fidence;   that   confidence   insures   co-operation; 


CONCLUSION  109 

and  that  co-operation  brings  results  satisfying 
not  alone  In  the  cure  of  the  Infected,  but  In  the 
stimulation  among  the  people  of  Intelligent 
interest  in  all  questions  pertaining  to  their 
health  and  physical  well-being. 


ILLUSTRATIONS 


14 

r 

Fig.  4.    Nurses  taking  treatment  to  the  patients  in  their 
homes.     St.  Vincent 


fig.  5.    Rear  view  of  fig.  4  showing  method  of  carrying 
drugs  and  equipment 


i;il»;^ii't^w'^'ui:"''"''J 


fig.  6.    Group  of  Alohammedans,  all  infected  with  hook- 
worm disease.    Mosque  in  background.     British  Guiana 


Fig.  7.    Mohammedan  bishop  and  family.    All  cured  of 
hookworm  disease.    Trinidad 


Fig.   8.     A  family  group.     All   infected  with   hookworm 
disease;    all  treated.    St.  Vincent 


Fig.c).  Company  of  soldiers.  Eighty-two  per  cent  infected 
with  hookworm  disease.    Cured  in  one  month.    St.  Lucia 


APPENDICES 


I 

RESULTS  ACCOMPLISHED 

Table  V  on  page  122  shows  the  degree  to  which  our 
campaigns  in  the  West  Indies  during  the  years  1914- 
1917  inclusive  have  approximated  the  complete  relief 
and  control  of  hookworm  disease  in  the  respective  colonies. 

By  consulting  this  table,  it  will  be  seen  that  the  per 
cents  opposite  the  line  "Remaining  in  Area  Uncured," 
as  based  on  the  number  of  persons  originally  infected, 
run  from  8.0  per  cent  in  Dutch  Guiana  to  26.1  per  cent 
in  St.  Lucia,  with  a  general  average  of  16.9  per  cent  for 
the  seven  colonies  represented.  With  an  average  of 
only  16.9  per  cent  of  the  original  infection  remaining  in 
these  areas,  with  the  people  thoroughly  understanding 
the  methods  by  which  the  disease  is  contracted  and 
prevented,  with  the  installation  of  latrine  systems  which 
with  continuous  government  supervision  should  become 
increasingly  effective,  it  would  seem  reasonable  to  expect 
that,  without  a  second  campaign  of  treatment,  the 
eradication  of  the  disease  in  the  different  areas  will  be 
attained  by  the  operation  of  preventive  measures  and 
by  the  self-limiting  character  of  the  infection  in  the 
individual. 


122 


APPENDIX 


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II 

FORMS  USED  IN  INTENSIVE  WORK 

The  information  collected  in  all  measures  for  the  relief 
and  control  of  hookworm  disease  falls  naturally  under 
one  of  two  heads:  one  relating  to  what  is  done;  the 
other,  to  what  is  learned.  The  first  object  of  the  work,  of 
course,  is  to  relieve  and  control  the  disease;  in  the  at- 
tempt to  do  this,  however,  much  information  of  value 
in  planning  further  work  is  incidentally  gained. 

It  is  necessary  to  have  some  systematic  method  of 
recording  and  reporting  the  results  of  the  work  in  both 
of  these  phases.  In  addition,  it  is  necessary  for  the  medi- 
cal director  to  have,  for  administrative  purposes,  certain 
forms  for  the  use  of  his  subordinates  in  collecting  and 
presenting  to  him,  daily  and  weekly,  the  results  and 
progress  of  the  work  in  the  field.  The  most  important 
forms  used  for  these  several  purposes  in  our  campaigns 
are  presented,  with  explanatory  notes,  in  the  following 
pages: 

The  Census  Book  (Form  127) 

The  book  for  the  use  of  nurses  in  taking  the  census 
provides  space  for  recording  the  house  number,  name, 
age,  sex,  and  race  of  individuals,  and  the  kind  of 
latrine  accommodations  found  at  their  homes.  The 
classification  of  latrines  as  shown  on  this  form  is  very 
general,  F  indicating  the  absence  of  any  latrine;  E  a 
latrine  for  privacy  only,  neither  preventing  soil  pollu- 
tion nor  being  screened  against  flies;  and  D  any  type 
of  latrine  effectually  preventing  soil  pollution  and  so 
constructed  that  it  is  fly  proof.  A  fourth  section  is  pro- 
vided  for  recording  types  of  latrines  which  may  be  of 

123 


124 


APPENDIX 


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126  APPENDIX 

special  significance  in  the  country  or  district  where  the 
inspection  is  made. 

Columns  are  provided  for  recording  the  dates  when 
containers  are  delivered  and  when  specimens  are  collected, 
and  at  the  right  there  is  a  space  for  remarks. 

The  census  books  are  usually  of  a  size  to  accommodate 
150  to  200  names.  It  is  not  desirable  to  have  them  larger, 
since  they  must  be  left  at  the  central  office  for  the  purpose 
of  recording  the  census  in  the  case-record  book,  and  it  is 
better  to  have  each  book  represent  only  one  or  two  days' 
work. 

The  Case-record  Book  (Form  100) 

1.  Purpose  of  the  Book.  The  case-record  book  has 
been  designed  to  provide  for  the  medical  record  of  each 
patient,  as  well  as  to  give  a  complete  census  of  the  area 
and  a  record  of  the  latrine  improvement  at  the  homes. 
By  combining  into  a  single  book  the  three  records  (i)  of 
census,  (2)  of  examination  and  treatment,  and  (3)  of 
latrine  improvement,  much  re-writing  may  be  saved. 
The  effort  has  been  made  to  make  the  case-record  book 
as  compact  as  possible.  There  are  twenty  lines  and  a 
total  on  each  page,  and  the  books  may  contain  100,  200, 
500,  or  more  pages. 

2.  Suggestions  for  Reporting.  A  sample  page  of 
the  case-record  book  follows.  It  will  be  seen  that  oppor- 
tunity is  afforded  for  accounting  for  every  person  in  the 
area  of  operation.  Opposite  the  name  of  each  person  it 
is  possible  to  indicate  whether  or  not  he  was  examined, 
and  if  not  examined,  the  reason;  if  infected,  whether  or 
not  he  was  given  first  treatment,  and  if  not  given  first 
treatment,  the  reason;  and  if  given  first  treatment, 
whether  or  not  he  was  cured,  and  if  not  cured,  the  reason. 
The  number  of  treatments  required  to  cure  each  person 


FORMS    USED    IN    INTENSIVE    WORK  I27 

may  also  be  recorded.  It  is  possible  in  this  way  to  exhibit 
the  thoroughness  of  the  work  by  showing  (i)  how  many 
of  the  persons  found  infected  were  cured,  and  (2)  how 
many  of  the  persons  found  infected  remained  in  the  area 
uncured  at  the  close  of  the  work.  Improvement  in  sani- 
tation will  be  indicated  by  comparing  latrine  conditions 
at  each  home  on  the  first  inspection  and  on  the  last.  A 
few  remarks  concerning  the  use  of  each  section  of  the 
blank  are  given  below: 

(i)  Patient's  Number.  The  first  column,  headed  "Pa- 
tient's Number,"  will  be  filled  in  when  the  names  in  the 
census  book  are  transferred  to  the  case  record. 

(2)  Name.  In  the  column  headed  "Name"  will  be 
entered  a  complete  census  of  the  area.  As  far  as  possi- 
ble the  names  in  this  column  will  be  entered  by  families, 
with  the  name  of  the  family-head  first.  The  surname 
will  be  followed  by  the  given  name. 

(3)  Residence.  The  column  headed  "Residence"  is  for 
recording  the  street  address  of  patients  living  in  towns, 
or  facts  which  may  be  of  aid  in  locating  homes  in  rural 
districts, 

(4)  House  Number.  The  column  headed  "House  Num- 
ber" will  be  used  in  countries  where,  for  the  sake  of 
convenience,  each  house  is  given  a  number  by  the 
census-taker, 

(5)  Sex.  In  the  column  headed  "Sex"  the  initials 
M  or  F  may  be  used  for  denoting  whether  the  person  is 
male  or  female. 

(6)  Jge.  The  section  headed  "Age"  has  five  divisions. 
The  exact  age  of  each  person  will  be  entered  in  the 
column  corresponding  to  the  age  group  to  which  he 
belongs. 

(7)  Race.  The  column  headed  "Race"  has  five  divi- 
sions corresponding  to  the  five  major  racial  divisions  of 


128  APPENDIX 

mankind.  The  term  "Brown  Race"  denotes  the  brown 
race  of  Malaya.  Persons  of  mixed  blood  will  be  entered 
according  to  the  predominating  element  in  their  blood. 
A  check  mark  in  the  proper  column  will  denote  the  race 
of  each  person. 

(8)  Examined.  In  the  section  headed  "Examined," 
space  is  provided  for  indicating  the  results  of  each  exami- 
nation from  the  first  to  the  eighth.  In  making  the  first 
examination,  specimens  are  usually  examined  incidentally 
for  other  parasites  in  addition  to  hookworm.  Under 
"First  Examination,"  therefore,  space  has  been  pro- 
vided for  recording  the  number  of  specimens  either  posi- 
tive or  negative  to  hookworm,  together  with  the  number 
of  specimens  positive  to  the  other  intestinal  parasites 
most  commonly  found,  including  Ascaris,  Trichocephalus, 
Strongyloides,  Oxyuris,  Tenia,  and  Ameba.  In  the 
columns  headed  "Second  Examination,"  "Third  Exami- 
nation," "Fourth  Examination,"  "Fifth  Examination," 
"Sixth  Examination,"  "Seventh  Examination,"  and 
"Eighth  Examination,"  space  is  provided  for  reporting 
upon  hookworm  only.  The  month  and  day  on  which 
each  examination  is  made  will  be  entered  and  a  check 
mark  used   for  indicating  which   parasites   are  found. 

When  the  examination  is  made  on  which  the  patient 
is  found  negative  to  hookworm,  the  month  and  day  will 
be  entered,  and  a  small  "c"  inserted  in  the  column  headed 
"Uncinaria"  to  indicate  that  a  cure  has  been  effected. 
The  addition  of  these  small  "c"-s  will  agree  with  the 
addition  of  the  column  headed  "Cured"  found  further 
to  the  right. 

It  will  be  noticed  that  space  has  been  provided  in  the 
case-record  book  for  recording  the  results  of  eight  exami- 
nations and  eight  treatments  only.  In  some  cases  more 
examinations    and   more   treatments   may   be   necessary. 


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FORMS    USED    IN    INTENSIVE    WORK  I29 

These  may  be  forwarded  to  a  new  page.  A  note  in  the 
"Remarks"  column  opposite  the  patient's  name  will  call 
attention  to  the  record  of  examination  and  treatment 
being  continued  elsewhere. 

(9)  Not  Examined.  In  the  section  headed  "Not  Ex- 
amined" are  four  divisions,  "Not  Located,"  "Refused," 
"Removed,"  and  "Died,"  to  be  used,  respectively,  for 
recording  persons  who  are  not  examined  either  because 
(i)  they  cannot  be  located,  (2)  refuse  to  be  examined, 
(3)  remove  before  examination,  or  (4)  die.  A  check 
mark  in  the  proper  column  will  indicate  the  reason 
for  any  person  not  being  examined. 

(10)  Treated.  The  section  "Treated"  has  eight  sub- 
headings: "First  Treatment,"  "Second  Treatment," 
"Third  Treatment,"  "Fourth. Treatment,"  "Fifth  Treat- 
ment," "Sixth  Treatment,"  "Seventh  Treatment,"  and 
"Eighth  Treatment."  Under  each  sub-heading,  space  is 
provided  for  the  month  and  day  on  which  each  treatment 
is  administered,  and  for  the  number  of  grains  of  thymol 
given. 

(11)  Not  Given  First  Treatment.  The  next  section, 
"Not  Given  First  Treatment,"  has  five  sub-headings: 
"Not  Located,"  "Refused,"  "Medical  Reasons,"  "Re- 
moved," and  "Died."  These  five  sub-headings  indicate, 
respectively,  five  reasons  for  failure  to  administer  first 
treatment,  as  follows:  (i)  the  patient  cannot  be  located 
after  examination,  (2)  he  refuses  to  accept  treatment, 
(3)  he  cannot  be  treated  for  medical  reasons,  (4)  he 
has  removed  before  treatment  can  be  given,  or  (5)  he 
has  died.  A  check  mark  in  the  proper  column  will  indi- 
cate why  any  particular  person  has  not  been  given  first 
treatment. 

(12)  Given  First  Treatment  but  not  Ciired.  The  sec- 
tion headed  "Given  First  Treatment  but   not   Cured," 


130  APPENDIX 

with  its  six  sub-headings,  "Not  Located,"  "Refused," 
"Medical  Reasons,"  "Removed,"  "Died,"  and  "Under 
Treatment,"  is  for  recording  persons  who  are  given  first 
treatment  but  are  not  kept  under  treatment  until  cured. 
A  check  mark  in  the  proper  column  will  indicate  why 
any  person  given  first  treatment  has  not  been  continued 
under  treatment  until  cured. 

(13)  Cured.  The  column  "Cured"  will  indicate,  by 
the  presence  or  absence  of  a  check  mark,  whether  or  not 
the  person  has  been  cured.  No  person  will  be  entered 
as  cured  until  he  has  been  found  negative  on  careful 
microscopic  re-examination   following  treatment. 

(14)  Latrine  Improvement.  The  heading  "Latrine  Im- 
provement" is  divided  into  twelve  columns,  six  under 
the  sub-heading  "First  Inspection,"  and  six  under  the 
sub-heading  "Last  Inspection."  Of  these  six  columns, 
four  are  for  recording  the  types  of  latrines  found,  and 
the  fifth  and  sixth  for  the  date  of  the  inspection.  The 
headings  of  the  four  columns  for  recording  the  types 
of  latrines  are,  respectively,  D,  E,  F,  and  "Other." 
The  significance  of  these  headings  is  as  follows:  D  indi- 
cates any  type  of  latrine  which  prevents  soil  pollution 
and  is  fly-proof.  This  includes  (i)  the  fly-proof  pail 
latrine,  where  the  ultimate  disposal  of  the  night  soil  is 
under  careful  supervision,  and  is  satisfactory;  (2)  the 
pit  latrine,  when  fly-proof  and  so  located  that  the  drink- 
ing-water supply  is  not  endangered  by  pollution;  (3)  sep- 
tic tanks  satisfactorily  constructed;  (4)  sewerage;  and 
(5)  incineration  plants.  The  E  denotes  any  types  of 
latrines  which  do  not  prevent  soil  pollution  or  which 
permit  flies  to  have  access  to  the  excreta.  This  includes 
(i)  all  latrines  built  for  privacy  only;  (2)  pail  latrines, 
where  disposal  is  unsatisfactory  and  the  latrines  are  not 
fly-proof;    (3)  pit  latrines  not  fly-proof  and  located  so  as 


FORMS    USED    IN    INTENSIVE    WORK  I3I 

to  endanger  the  drinking-water  supply;  and  (4)  septic 
tanks  improperly  constructed  or  not  kept  in  order.  F 
indicates  no  latrine  of  any  kind.  The  column  headed 
"Other"  is  for  recording  any  special  types  which 
may  be  of  particular  significance  in  the  country  or  dis- 
trict where  the  inspection  is  made. 

Two  inspections  are  provided  for:  first  and  last. 
The  first  inspection  is  made  when  the  census  of  an  area 
is  taken.  The  last  may  be  made  at  the  close  of  the 
campaign  or  later,  as  determined  by  the  medical  director. 
A  comparison  of  the  results  of  the  two  inspections  will 
indicate  the  latrine  improvement  resulting  directly  or 
indirectly  from  the  campaign. 

In  recording  the  results  of  a  latrine  survey  under  these 
heads,  one  latrine  is  recorded  for  each  household.  Where 
one  large  latrine  serves  several  households,  the  type  of 
this  latrine  is  recorded  as  many  times  as  there  are  house- 
holds using  the  latrine. 

Microscopic  Report  Sheet  (Form  130) 

This  sheet  is  for  the  use  of  the  chief  microscopist  in 
recording  the  daily  work  of  his  department.  By  using 
the  initial  letter  of  each  microscopist  or  a  distinguishing 
number  to  indicate  positive  findings,  the  comparative 
efficiency  of  each  microscopist  is  made  evident. 

The  headings  of  the  first  three  columns  on  this  form 
may  need  some  explanation.  In  Column  i,  "House 
Number "  indicates  the  number  of  the  home  in  which 
the  individual  lives.  In  Column  2,  "Patient's  Number" 
is  the  number  given  the  patient  in  the  case-record  book. 
In  Column  3,  "Examination  Number"  indicates  whether 
the  examination  is  the  first,  second,  third,  etc. 


132 


APPENDIX 


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134  '  APPENDIX 

Treatment  Book  (Form  128) 

This  book  is  for  the  use  of  the  nurses  in  giving  treat- 
ment in  the  field.  In  it  are  recorded  the  name  of  the 
area,  the  number  of  the  nurse's  district,  the  name  of  the 
nurse,  and  the  house  number,  patient's  number,  name, 
age,  and  sex  of  every  infected  person  in  the  nurse's  dis- 
trict. Following  each  name,  columns  are  provided  for 
recording  the  dose  of  the  anthelmintic,  the  date,  and  the 
result  of  re-examination  following  each  treatment.  It 
will  be  noted  that  the  column  for  re-examinations  first 
appears  after  second  treatment,  and  then  successively 
after  each  treatment.  It  has  not  been  found  necessary 
to  examine  the  patients  after  the  first  treatment,  since 
so  few  are  cured  by  one  treatment.  Columns  are  pro- 
vided for  eight  treatments  and  seven  re-examinations. 

These  books  should  be  of  a  size  to  accommodate  200 
names,  which  is  probably  the  maximum  number  of  in- 
fected people  that  will  be  included  in  a  nurse's  district. 

Nurses'  Reports:    Daily,  Weekly,  and  Summary 
(Forms  131,  132,  and  129) 

The  three  following  forms  for  nurses'  reports  are  for 
administrative  purposes  only: 

1.  Nurses'  Daily  Report  Sheet.  In  order  to  keep 
the  medical  director  informed  of  the  progress  of  the  work 
and  of  the  efficiency  of  the  nurses,  each  nurse  is  required 
to  make  a  daily  report  of  the  work  accomplished  in  his 
district.  Form  131  is  for  this  purpose  and  provides  for 
reporting  the  total  number  of  patients  under  treatment, 
the  number  of  first  to  eighth  treatments  given,  and  the 
number  of  specimens  collected.  The  nurse's  name,  the 
district,  and  the  date  also  form  a  part  of  each  daily  report. 


FORMS    USED    IN    INTENSIVE   WORK  I35 

2.  Nurses'  Weekly  Report  Sheet.  This  report  is 
more  elaborate  than  the  daily  report,  as  it  shows  the 
progress  in  each  nurse's  district  by  weeks,  from  the  begin- 
ning to  the  close  of  the  work.  At  the  end  of  each  week 
entries  are  made  on  this  sheet  showing  the  name  of  the 
nurse  and  the  number  of  people  found  positive.  Under 
the  heading  "Before  Treatment"  there  are  recorded  the 
"Number  not  treated  for  medical  reasons,"  "Number 
removed,"  "Number  refusing  treatment,"  "Number  not 
located,"  and  "Number  died";  in  eliminating  these  from 
the  "Number  positive,"  we  have  the  "Total  number 
available  for  treatment."  Of  those  "Available  for  treat- 
ment," those  "Given  first  treatment"  appear  in  the  proper 
column  and  also  the  "Total  number  of  treatments"  given. 
Under  the  heading  "After  Treatment"  are  columns  for 
the  "Number  cured,"  the  number  "Discontinued  treat- 
ment for  medical  reasons,"  "Number  removed,"  "Num- 
ber refused,"  and  "Number  died."  Three  additional 
columns  provide  space  for  recording  the  "Number  re- 
maining after  first  treatment,"  the  "Number  under 
treatment,''  and  the  "Number  now  available  for  treat- 
ment." A  consideration  of  all  of  these  facts  at  the 
end  of  each  week  shows  the  director,  not  only  the  prog- 
ress of  the  work,  but  its  extent  in  the  beginning  in  that 
particular  district  and  its  progress  toward  completion. 

3.  Nurses'  Weekly  Summary  Report  Sheet.  Upon 
this  sheet  is  summarized  all  information  contained  in 
the  nurses'  weekly  reports.  At  a  glance  the  Director  can 
see  the  status  of  work  in  any  nurse's  district  and  judge  of 
the  efficiency  of  that  nurse,  and  he  can  also  sum  up  the 
situation  for  the  entire  area  of  operation. 


136 


APPENDIX 


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144  APPENDIX 

The  Diary  (Form  48) 

The  diary  (Form  48)  is  intended  to  record  information 
on  educational  work.  It  is  designed  to  be  small  enough 
to  be  carried  conveniently  by  the  medical  director.  Each 
page  provides  space  for  recording  the  educational  work  of 
three  days.  At  the  top  of  the  section  for  each  day  will 
be  written  the  date,  and  the  town,  village,  or  locality 
visited  by  the  medical  director.  The  number  of  lectures 
delivered,  the  attendance  at  each,  and  the  number  of 
pieces  of  literature  distributed,  by  classes,  will  then  be 
inserted  in  the  spaces  provided.  A  sample  page  of  the 
diary  appears  on  page  145. 

Educational  work  may  be  roughly  divided  into  two 
main  classes:  first,  that  by  lectures;  and  second,  that  by 
literature.  Lectures  are  of  three  kinds:  public,  to  an 
audience  of  twenty  or  more  persons  not  selected  in  any 
way;  school,  to  an  audience  composed  of  school  children; 
and  special,  to  any  group  of  persons  belonging  to  a  special 
class,  such,  for  instance,  as  teachers,  physicians,  or 
mothers.  Literature  falls  into  four  general  classes:  first, 
letters;  second,  pamphlets;  third,  leaflets;  and  fourth, 
notices  or  bulletins.  The  first  includes  all  personal  or 
circular  letters  written  to  any  person  in  behalf  of  the 
work;  the  second,  printed  books  or  booklets  more  than 
four  book  pages  in  length;  the  third,  the  same  class  of 
printed  matter  as  the  second  but  less  than  four  pages  in 
length;  while  the  fourth  class  includes  notices  or  bulle- 
tins (placards)  printed  on  a  single  sheet,  giving  notices  of 
public  meetings  and  other  features  connected  with  the 
work.  Educational  work  in  all  of  its  phases  is  of  course 
much  more  extensive  than  this,  but  it  is  believed  that 
space  has  been  provided  for  all  of  the  features  connected 
with  this  work  which  it  is  possible  definitely  to  report. 


FORMS    USED    IN    INTENSIVE    WORK 


145 


FORM.  40 
DATE                                              PLACE 

LECTURES   DELIVERED 

LITERATURE    DISTRIBUTED                                  | 

KIND 

NUMBER 

ATTENDANCE 

KINO 

NUMSER 

PUBLIC 

LETTERS 

SCHOOL 

PAMPHLETS 

SPECIAL 

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NOTICES  ^BULLETINS 

TOTAL 

TOTAL 

REMARKS 

FORM   46 
DATE                                              PLACE 

LECTURES    DELIVERED 

Literature  Distributed                        | 

KIND 

NUMBER 

ATTENDANCE 

KIND 

NUMBER 

PUBLIC 

letters 

SCHOOL 

pamphlets 

SPECIAL 

LEAFLETS 

NOTICES  aeULLETINS 

TOTAL 

total 

Remarks 

FORM    48 
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LECTURES    DELIVERED 

LITERATURE  DISTRIBUTED                                  j 

KIND 

NUMBER 

ATTENOANCe 

KINO 

NUMBER 

PUBLIC 

LETTERS 

SCHOOL 

PAMPHLETS 

SPECIAL 

LEAFLETS 

NOTICESa  BULLETINS 

TOTAL 

TOTAL 

REMARKS 

Fig.  17.  —  Page  of  Diary,  Form  48 
(Reduced  facsimile;  actual  measurement  4  x  61'.) 


146  APPENDIX 

The  records  of  educational  work  as  kept  In  the  diary 
are  transferred  at  the  close  of  the  work  in  each  area  to 
the  section  headed  "Educational  Work"  on  Form  133. 

Geographical  Area  Report  on  Completed  Work 
(Form  133) 

The  geographical  area  report  on  completed  work  pro- 
vides space  for  all  of  the  details  usually  reported  upon  in 
work  by  the  intensive  method.  In  it  a  complete  sum- 
mary of  the  work  in  any  geographical  area  may  be  given. 
It  is  not  prepared  until  the  work  in  the  area  has  ended. 
These  reports  are  furnished  in  duplicate,  one  for  the 
government  of  the  country  where  the  work  is  in  progress, 
and  the  other  for  the  International  Health  Board.  It  is 
important  that  they  cover  the  entire  field  of  activities  of 
the  force,  and  at  the  same  time  be  simple  but  intelligible, 
requiring  the  minimum  of  the  director's  time  and  atten- 
tion in  their  preparation. 

All  of  the  information  requested  on  this  form  is  obtained 
from  the  case-record  book  (Form  100)  except  that  for 
"Educational  Work."  Information  on  educational  work 
is  recorded  in  the  diary  (Form  48)  and  is  obtained  from  it. 
It  is  believed  that  sufficient  explanation  of  the  headings 
on  the  geographical  area  report  has  already  been  given  in 
the  pages  describing  the  case-record  book  and  the  diary. 

Quarterly  Report  on  Completed  Work  (Form  50) 
This  report  is  prepared  and  forwarded  by  the  medical 
director  at  the  end  of  each  quarter.  It  is  intended  to 
show  at  a  glance  the  results  accomplished  in  geographical 
areas  in  which  work  has  been  completed  during  the  quar- 
ter. The  information  it  contains  is  taken  entirely  from 
the  geographical  area  report.  Two  copies  of  the  report 
are  prepared,  as  in  the  case  of  Form  133,  and  one  for- 
warded with  the  latter  form  to  the  government,  the  other 
to  the  International  Health  Board. 


forms  used  in  intensive  work  i47 

Quarterly  Report  on  Work  in  Progress 
(Form  51) 

This  report  is  also  prepared  and  forvN^arded  by  the 
medical  director  at  the  end  of  each  quarter.  It  is  intended 
to  show  at  a  glance  the  results  accomplished  in  geo- 
graphical areas  in  which  the  work  has  been  in  progress  but 
has  not  been  completed  at  the  end  of  the  quarter.  It  is 
identical  with  Form  50  in  all  respects  except  the  heading. 
For  Form  51  no  supporting  geographical  area  reports  are 
desired.  Two  copies  of  the  report  are  prepared  as  with 
Forms  133  and  50,  one  being  forwarded  to  the  govern- 
ment and  the  other  to  the  International  Health  Board. 

Special  Monthly  Report  for  the  Information 
OF  Regional  Directors 

The  regional  directors  of  territories  in  which  intensive 
work  is  being  conducted  may  wish  to  keep  more  inti- 
mately in  touch  with  the  progress  of  the  work  than  can 
be  done  by  means  of  the  regular  quarterly  reports  above 
described.  This  may  be  accomplished  by  having  the 
medical  director  in  charge  of  the  work  in  each  country 
mail  monthly  to  the  regional  director  a  special  report  on 
a  form  similar  to  that  shown  on  page  154.  This  will  give 
information  concerning  the  total  results  accomplished  by 
the  staff  during  the  month,  irrespective  of  the  areas  in 
which  it  was  engaged,  while,  by  showing  the  number  of 
employes  of  each  class,  it  will  enable  the  regional  director 
to  measure  progress  and  to  apply  pressure  if  satisfactory 
results  are  not  being  obtained  in  every  department. 

Narrative  Report 

Each  quarterly  statistical  report  is  usually  accompanied 
by  a  narrative  report  prepared  by  the  medical  director. 


148 


APPENDIX 

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154  APPENDIX 


MOCTHLY  REPORT  FOR  THE   I1JF0R1IA.TI0H  OF  THE 

RSGIOMAL  DIRECTOR  FOR  THE , 

territory 

Report  of  the  hookworm  campaign  in  ,  for  the  month  of 

name  of  country 


(1)  Additions  to  census 

(2)  Refused  examination 

(3)  Removed  before  examination 

(4)  First  examinations  made 

(5)  Re-examinations 

(3)  Total  microscopic  examinations 

(7)  First  treatments  given 

(8)  Treatments  refused 

(9)  Removed  before  cured 
( 10  )  Total  treatments 
(11)  Cured 

(12).  Expenditures  for  month: 

Medical  director,  salary  and 
traveling  expenses 

Rest  .of  staff 

(13)  number  of  micropists'  employed 

(14)  Number  of  nurses  employed 

(IB)   Remarks      ____^___________ 


(Sigijed) 


Uedioal  Director 


Fig.  21.  —  Special  Monthly  Report  For  Information  of 

Regional  Directors 

(Reduced  facsimile;  actual  measurement,  8|  x  1 1  *) 


FORMS    USED    IN    INTENSIVE    WORK  1 55 

When  a  new  area  of  operation  is  entered,  this  narrative 
report  deals  with  the  population,  its  nature  and  distri- 
bution, living  conditions,  topography  of  the  area,  and  a 
general  description  of  the  conditions  to  be  met. 

Narrative  reports  on  areas  where  work  is  in  progress 
may  be  brief,  setting  forth  interesting  features  which 
have  developed  and  the  progress  made  in  the  area. 

The  narrative  report  of  a  completed  area  is  expected 
to  combine  all  information  given  in  previous  narrative 
reports  regarding  this  area,  and  to  give  a  final  summing 
up  of  results  and  the  local  conditions  which  have  favored 
or  hindered  the  work.  In  addition,  this  report  may 
mention  the  general  conditions  responsible,  in  the  begin- 
ning, for  the  presence  and  spread  of  hookworm  disease, 
and  the  measures  taken  to  remedy  these  conditions. 

The  annual  narrative  report  obviously  should  deal 
with  the  work  and  experiences  of  the  entire  year  and 
is  more  or  less  a  combination  of  all  narrative  reports  for 
the  year. 

Budget  (Form  12) 

Each  budget  is  a  detailed  statement  of  the  funds  re- 
quired for  work  in  a  country  or  a  state,  or  by  a  definite 
unit  of  working  force  during  a  fixed  period  of  time.  A 
typical  annual  budget  for  a  standard  unit  of  working  force 
where  work  is  done  by  the  intensive  plan  is  shown  on 
pages  156-157.  Where  there  are  several  units  of  force 
operating  in  a  state  or  country,  each  has  its  own  budget. 
Each  budget  bears  in  its  upper  right-hand  corner  a  serial 
number  by  which  it  is  known,  and  each  item  for  which 
the  expenditure  is  fixed  is  given  an  independent  item- 
number.  After  being  duly  approved  and  signed  by  the 
proper  authority,  the  total  expenditure  authorized  by  a 
budget,  or  the  amount  set  apart  for  any  of  its  numbered 
items,  cannot  be  changed,  or  the  funds  under  one  item 


156 


APPENDIX 


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FORMS    USED    IN    INTENSIVE    WORK 


157 


158  APPENDIX 

be  applied  to  expenses  under  another,  except  by  the 
authorization  and  issuance  of  a  new  budget  embodying 
the  necessary  modifications  and  bearing  another  serial 
number.  As  a  separate  account  is  kept  of  the  expendi- 
tures under  each  numbered  item,  in  arranging  supersed- 
ing budgets  it  is  essential  not  to  disturb  the  previously 
assigned  item-numbers,  as  this  would  lead  to  confusion 
of  accounts. 

In  the  experience  of  the  International  Health  Board 
in  the  foreign  field  it  has  been  found  that  items  such 
as  drugs,  scientific  instruments,  etc.,  in  certain  cases 
may  be  purchased  more  advantageously  in  the  United 
States  than  either  locally  or  in  European  markets.  In 
such  cases  funds  to  pay  for  these  items  are  held  in 
the  Home  Ofl&ce  to  avoid  double  charges  for  exchange, 
and  such  amounts  are  designated  "Home  Office  Funds." 
All  budgetary  funds  which  are  to  be  expended  in  the 
country  where  work  is  in  progress,  such  as  salaries,  rent, 
office  furniture,  etc.,  are  known  as  "Field  Office  Funds.'* 

Budgets  are  usually  arranged  to  provide  funds  for  a 
definite  working  force  operating  during  a  calendar  year. 
In  certain  cases  they  are  made  for  a  shorter  time,  but 
they  never  overlap  from  one  calendar  year  to  another. 
At  the  end  of  a  calendar  year  all  unexpended  budgetary 
funds  automatically  revert  to  the  source  of  such  funds, 
which  in  our  work  in  the  West  Indies  is  the  Interna- 
tional Health  Board,  only  becoming  available  for  ex- 
penditure by  official  action  appropriating  them  to  the 
needs  of  a  new  budget. 

Explanatory  Notes  on  Budget 

1.  Salaries.  The  salary  and  traveling  allowance  of 
the  medical  director  (item  i)  are  not  included  in  the 
budget,  as  these  are  subject  to  wide  variations  accord- 


FORMS    USED    IN    INTENSIVE    WORK  1 59 

ing  to  the  country  where  such  work  is  undertaken  and 
the  grade  of  service  from  which  the  medical  director  is 
secured.  No  traveling  allowance  is  made  to  any  mem- 
ber of  the  force  except  the  medical  director. 

The  maximum  salary  of  chief  clerks  in  the  West  Indies 
{item  2)  is  placed  at  $50.00  per  month.  As  a  rule  they 
may  be  employed  for  less.  The  assistant  clerk  is  never 
paid  more  than  $35.00  per  month. 

The  maximum  salary  of  the  chief  microscopists  {item 
3)  has  been  fixed  at  $40.00  per  month;  the  assistant 
microscopists  receive  from  $25.00  to  $35.00  per  month. 

The  maximum  salary  of  the  chief  nurse  {item  4)  is 
$40.00  per  month.  The  nurses  are  paid  from  $25.00  to 
$35.00  per  month.  The  annual  estimate  of  $4,200,  or 
$350.00  per  month,  for  the  item  of  assistant  nurses  in 
the  sample  budget,  is  based  on  the  following  arrangement 
of  salaries: 

Per  month  Per  year 

6  Nurses  at  ^25.00  per  month ^150.00  ^1800.00 

3       "        "     30.00    "         "      90.00  1080.00 

3       "        "     35.00    "        "      105.00  1260.00 

The  additional  $5.00  per  month  is  for  bonuses  for  the 
nurses  showing  the  highest  efficiency  in  their  work. 

The  caretaker  {item  5)  is  usually  a  woman  who  lives 
near  the  laboratory  office  and  who  may  be  employed  for 
a  comparatively  small  salary. 

2.  Office  Equipment.  The  equipment  {item  6)  con- 
sists of  the  following  items: 


(i)  Office  and    laboratory    furniture,    including    tables,    one    type- 
writer, chairs,  lockers,  file  cases,  bowls,  buckets,  towels,  etc. 

(2)  Stationery,  envelopes,  etc. 

(3)  Rents,  light,  and  water  supply  in  office  and  laboratory. 

(4)  Printing  of  record  books,  forms,  literature,  etc. 


l60  APPENDIX 

3.  Scientific  Equipment.  This  equipment  for  one 
unit  of  force  {item  i8)  consists  of  the  following  items: 

1  Microscope,    portable,    equipped    with    triple    revolving   nose- 

piece;  objectives  i6,  4,  and  1.9  m.m.;  Abbe  condenser,  screw 
sub-stage.     (Cat.  No.  APS-8.) 

3  Microscopes,  portable,  equipped  with  double  revolving  nose- 

piece;    objectives   16  and  4  m.m.;    two  eye-pieces,   5   and 
loX.     (Cat.  No.  APS-4.) 

4  Mechanical  stages  to  fit  above  microscopes  and   adapted  to 

use  of  2  X  3"  slides. 
2,000  Microscope  slides,  2x3*. 

2  Special  double-speed  hand  centrifuges  with  Stewart  panheads. 
600  Special  tubes  for  Stewart  panheads. 

112,500  Corks  for  centrifuge  tubes. 

300  Funnels  to  fit  centrifuge  tubes.     - 
1,600  Flat-bottom  vials. 
250,000  Flat  wooden  toothpicks. 

6  Talquist  hemoglobin  index  books. 

I   Balopticon,  with  accessories  consisting  of  2  Prest-0-Lite  gas 
tanks,  I  screen,  i  standard  set  lantern  slides,  2  hookworm 
charts. 
I  Camera,  with  accessories,  as  follows: 

I  Leather  carrying-case,  i  tripod,  2  dozen  6-exposure  film 
rolls  in  tin. 
450  Gross  containers.^ 

4.  Drugs.  The  amount  allowed  for  drugs  {item  19) 
is  based  upon  the  supposition  that  one  unit  of  force  will 
handle  a  population  of  15,000  people  annually,  where 
there  is  an  average  rate  of  infection  of  65  per  cent.  This 
would  mean  that  in  a  year  the  one  unit  of  force  would 
need  to  treat  approximately  9,750  infected  people.  The 
average  amount  of  thymol  necessary  to  cure  an  adult 
case  is  120  grains.  This  would  be  administered  in  cap- 
sules which  contain  10  grains  of  finely  powdered  thymol 
combined  with  approximately  an  equal  quantity  of  milk 


^  Experience  shows  that  with  an  average  infection  of  65  per  cent, 
30  gross  of  tin  specimen  containers  are  required  for  each  one  thousand 
of  population.  For  a  population  of  15,000,  450  gross  would  be  required, 
which  at  the  present  price  of  75  cents  per  gross  would  cost  approx- 
imately $337.50. 


FORMS    USED    IN    INTENSIVE    WORK  l6l 

sugar.  Twelve  of  these  capsules  would  be  required  as  an 
average  to  each  case.  About  one-fifth  of  the  cases  found 
infected  are  usually  children  who  require  only  one-half 
the  adult  dose  of  thymol,  or  60  grains.  For  use  with 
children,  the  thymol  is  put  up  in  gelatin  capsules  also, 
each  containing  5  grains  of  powdered  thymol  and  an 
equal  quantity  of  milk  sugar.^  An  average  of  twelve 
capsules  is  required  for  each  case  treated.  The  prices 
for  these  capsules  are  very  high  at  present  and  are  subject 
to  change  owing  to  the  decrease  in  the  production  of 
thymol  because  of  the  war,  thymol  having  advanced 
300  per  cent  in  the  last  two  years. 

The  following  table  shows  in  detail  the  annual  estimate 
for  thymol  for  one  unit  of  force: 

To  be  treated  Thymol  capsules  required  Cost 

Children     1,950  23,400    5  grain  $300.83 

Adults        7,800  93,600  10  grain  $2,481.52 

Total      9,750  117,000  $2,782.35 

Sulphate  of  magnesia  has  seemed  to  serve  best  as  the 
agent  to  be  used  in  clearing  out  the  alimentary  canal, 
both  before  and  after  the  administration  of  thymol.  It 
is  estimated  that  each  adult  case  treated  will  require 
two-thirds  of  a  pound  of  magnesium  sulphate,  and  each 
child  one-half  pound.  At  present  this  salt  in  bulk,  packed 
in  kegs  of  125  pounds  each  for  ocean  transportation,  is 
costing  approximately  4I  cents  per  pound.  The  follow- 
ing table  shows  in  detail  the  annual  estimate  for  mag- 
nesium sulphate  for  one  unit  of  force: 

To  be  treated  Magnesium  sulphate  required  Cost 

Children     1,950                         975  pounds  $43.88 

Adults        7,800                      5,200       "  $234.00 

Total      9,750                      6,175       "  $277.88 


^  The  powder  is  taken  out  of  the  capsule  and  administered  with 
water  or  in  syrup  in  cases  of  children  too  small  to  swallow  the  capsule. 


l62 


APPENDIX 


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163 


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164  APPENDIX 

The  estimated  cost  of  thymol  capsules  and  magnesium 
sulphate  thus  amounts  to  approximately  ^3,000  annually 
for  each  unit  of  force. 

5.  Contingent  Fund.  The  contingent  fund  (items 
7  and  20)  is  intended  to  meet  emergency  expenses  not 
otherwise  provided  for  in  the  budget,  such  as  freight, 
cartage,  postage,  etc.  A  part  of  the  contingent  fund  is 
usually  allotted  to  "Field  Office  Funds"  and  the  re- 
mainder to  "Home  Office  Funds." 

Note  should  be  made  of  the  fact  that  a  large  part  of 
the  expenditure  under  6  and  18,  is  for  permanent  office 
and  scientific  equipment.  A  force  once  fully  equipped 
will  require  subsequently  but  a  very  small  outlay  for 
minor  supplies  under  these  heads. 

Quarterly  and  Yearly  Financial  Reports 
(Form  24) 

The  financial  report  form  shown  on  pages  162  and  163 
has  been  prepared  for  use  by  Medical  Directors  in  the 
field  in  reporting  receipts  and  expenditures.  This  form 
is  so  worded  as  to  be  adapted  to  a  report  covering  a 
year  or  any  other  period. 

In  making  out  the  financial  reports  care  should  be 
taken  to  observe  the  following: 

(i)  After  "For"  at  the  top  of  the  form  put  the  name 
of  the  country,  area,  or  other  description.  Copy  the 
exact  words  used  in  this  place  on  the  Budget. 

(2)  Under  "Receipts  during  Period"  describe  accu- 
rately the  checks,  drafts,  letters  of  credit,  and  other  forms 
of  remittance. 


Ill 

LIST  OF  STANDARDIZED  SUPPLIES  AND 
PRICES 

Since  the  outbreak  of  the  Great  War  it  has  become 
very  difficult  for  medical  directors  to  buy  and  secure 
prompt  delivery  of  supplies  of  any  nature  directly  from 
the  manufacturers.  This  has  led  the  International  Health 
Board  to  offer  its  services  to  the  medical  directors  in 
various  countries  to  place  orders  for  supplies  and  expedite 
the  shipment  of  these  as  much  as  possible.  No  charge  is 
made  for  this  service. 

The  following  is  a  list  of  supplies  for  which  the 
International  Health  Board  is  prepared  to  place 
orders.  The  prices  given  are  approximate  only  and 
subject  to  change: 

APS-8  Portable  Microscope,  equipped  with  triple  revolving  nose-piece; 

objectives  i6,  4  and  1.9  m.m.;   two  eye-pieces  5  and  loX;   Abbe 

condenser  in  quick  acting  screw  sub-stage. 

Price  $72.50  each. 
APS-4  Portable    Microscope,    equipped   with    double    revolving   nose- 
piece;  objectives  16  and  4  m.m.;   and  two  eye-pieces  5  and  loX. 

Price,  $40.50  each. 
No.  2 1 16  Mechanical  Stages  for  above  microscopes. 

Price,  $16.00  each. 
2x3"  Microscope  Slides  (500  per  microscope). 

Price,  $2.25  per  100. 
Talquist  Hemoglobin  Scale  Books. 

Price,  $1.75  each. 
No.  19002  Double-speed  hand  Centrifuge  without  sedimentation  attach- 
ment, hematokrit,  or  accessories  of  any  kind,  with  separate  clamp. 

Price,  $5.50  each. 
Stewart  panheads  for  double-speed  hand  Centrifuges,  equipped  with 

nut  for  fastening  on  centrifuge,  and  without  milk  tubes,  rubber 

corks,  and  nipples  regularly  supplied. 

Price,  $9.00  each. 
Special  Tubes  for  Stewart  panhead,  heavy  wall. 

Price,  $1.50  per  100. 
Corks  for  Tubes,  No.  O,  XXXX  quality. 

Price,  $.20  per  100. 

i6s 


l66  APPENDIX 

Glass  Funnels,  40  m.m.,  to  fit  special  tubes. 

Price,  $18.00  per  lOO. 
Vials,  flat-bottom,  25  m.m.  high,  15  m.m.  diameter. 

Price,  $1.00  per  100. 
Prest-O-Lite  Gas  Tanks,  10  cubic  feet. 

Price,  $10.00  each. 
Model  "C"  Balopticon,  with  acetylene  burner. 

Price,  $52.20  each. 
Tin  Containers  {\  ounce). 

Price,  $0.75  per  gross. 
Cases  of  Toothpicks,  each  containing  180,000. 

Price,  $2.50  per  case. 
Standard  Set  of  Lantern  Slides,  containing  47  slides  numbered  I  to  55 

inclusive,  excepting  Nos.  31,  43,  44,  46,  47,  48,  49  and  54. 

Price,  $.27!  each. 
Lantern  Slide  Carrying  Case,  Style  "C,"  detachable  cover,  Cat.  No. 

3660,  for  80  slides. 

Price,  $2.25  each. 
3-A  Autographic  Kodak,  with  Kodak  Anastigmat  Lens,  f.  7.7,  and  Au- 
tomatic shutter. 

Price,  $32.50. 
Black  Sole  Leather  Case  with  strap. 

Price,  $2.00  each. 
Films  for  Camera,  6-exposures,  in  sealed  tins. 

Price,  $.40  per  roll. 
Hookworm  chart,  International  Health  Board, 

Price,  $5.00  each. 
Thymol,  in  bulk,  crystalline,  in  25-pound  tins. 

Price,  $16.00  per  pound. 
Cost  of  capsulating  Thymol: 

Thymol,  10  grains;  sugar  of  milk,  8  grains,      $3.20  per  1,000 

Thymol,  5  grains;  sugar  of  milk,  5  grains,        $1.20 

Thymol,  2^  grains;  sugar  of  milk,  23  grains,       $.90 

Allowing  2%  for  waste, 

1,000    25  grain  capsules  require       .3642  pounds  Thymol, 
1,000     s       "  "  "  .7285       " 

1,000  10       "  "  "         I.4S7 

(The  pounds  used  here  are  avoirdupois) 
Magnesium  Sulphate,  in  kegs  of  125  pounds  each. 

Price,  $.04^  per  pound. 
Oil  of  Chenopodium,  in  bulk,  packed  in  i-gallon  jacketed  tins. 

Price,  $60.00  per  gallon. 
Oil  of  Chenopodium,  10  minim  flexible  capsules  (not  recommended). 

Price,  $26.10  per  1,000. 
Oil  of  Chenopodium,  5  minim  flexible  capsules  (not  recommended). 

Price,  $14.60  per  1,000. 


LIST   OF    STANDARDIZED    SUPPLIES   AND    PRICES 


167 


Capsules  required  for  1  gal.  Chenopodium 
I  Gal.  =  61440  minims  U.S.  Apoth.  Fluid  Measure 


Quantity  Chenopodium       * 
Gal.  chenopodium  requires 


Contents 

capsules 

capsules 

No.  capsules 

000 

16  minims  each            3840 

00 

14  minims     ' 

4389 

0 

9  minims     ' 

6827 

I 

7  minims     ' 

8778 

2 

5  minims     ' 

12288 

3 

4  minims     ' 

15358 

4 

3  minims     * 

'            20480 

S 

2  minims     ' 

*            30720 

for  imp 

effect  capsule 

s.     These  often 

amount  to  as  much  as  10%. 


Apparent  Age  of  Patient  ^ 


I 

to 

S  years 

6 

to 

lO      " 

11 

to 

IS     " 

i6 

to  20       " 

21 

to 

SO     " 

Over 

SO     " 

IV 

DOSAGE  TABLE 

lYMOL  AND  Solution  Magnesium 

Sulphate 

1            Dose  of  Thymol 

Dose  of  Magnesium 
Sulphate  Solution 

3  to    s  grains 
10  to  IS      " 
IS  to  30      " 
30  to  4S      " 
45  to  60      " 
30  to  4S      " 

2  drachms 

4 

6 

8 

12        " 
12        " 

The  magnesium  sulphate  solution  is  prepared  by  dis- 
solving 15  pounds  of  the  salts  in  3  gallons  of  boiling  water. 
This  gives  approximately  a  2  to  i  solution,  i.e.,  2  drachms 
contain  in  solution  i  drachm  of  magnesium  sulphate. 


^  In  arranging  dosage  by  "Apparent  age  of  patient,"  it  is  intended 
that  the  age  in  years  should  not  be  the  only  factor,  but  that  due  con- 
sideration should  be  given  to  the  robustness,  development,  and  size  of 
the  patient. 


168 


V 

GENERAL  INSTRUCTIONS   FOR  NURSES 

The  nurse  must  discontinue  treating  persons  who  de- 
velop the  following  conditions  during  the  course  of 
treatment,  and  must  not  resume  their  treatment  until 
directed  to  do  so  by  the  medical  director: 

(i)  Very  old  and  feeble  persons  who  are  markedly  de- 
pressed by  the  treatment. 

(2)  Children  under  five  years  of  age  who  are  made  ill 
by  the  treatment. 

(3)  Persons  who  develop  acute  malaria,  dysentery, 
diarrhea,  rheumatism,  or  fevers. 

(4)  Pregnant  women.  These  should  never  be  treated 
outside  of  hospital. 

(5)  Persons  who  develop  dropsical  swelling  of  face  or 
lower  limbs. 

Before  treating  a  person  showing  signs  of  ill  health,  the 
nurse  should  make  inquiries  to  ascertain  if  any  of  the 
following  conditions  exist: 

(i)  Swelling  or  dropsy  of  the  feet  and  ankles,  or  face; 
or  bloody  urine  and  suppression  of  urine.  These  are 
often  indications  of  kidney  affections  which  contraindi- 
cate  the  administration  of  both  thymol  and  chenopodium. 

(2)  A  recent  attack  of  dysentery  or  diarrhea,  or  the 
existence  of  either  of  these  in  chronic  form. 

(3)  Recent   acute   malarial   attack.     Often   the  giving 

of  magnesium  sulphate  will  precipitate  a  severe  malarial 

chill   where    a   chronic   malarial   infection   exists,    and    if 

this  occurs  in  giving  the  treatment  for  hookworm  disease 

the  treatment  is  held   responsible  for  the  illness  which 

results. 

169 


170  APPENDIX 

(4)  Extreme  shortness  of  breath  on  sHght  exertion, 
pulsation  of  the  veins  in  the  neck,  or  extreme  palpitation 
and  irregularity  in  the  heart's  action,  with  cough.  These 
symptoms  may  indicate  a  dangerous  organic  heart  lesion 
which  would  make  the  treatment  for  hookworm  disease 
unsafe. 

(5)  A  chronic  cough,  with  loss  of  flesh,  and  evening 
fevers  and  sweat.  It  is  not  safe  to  give  treatment  to  well- 
developed  cases  of  pulmonary  tuberculosis  except  in 
hospitals. 

(6)  In  female  patients  between  the  ages  of  15  and  45 
the  possibility  of  an  unsuspected  pregnancy  should  be 
investigated  before  treatment  is  administered. 

Directions  to  Nurses  for  Administering 
Treatments 

(i)  A  dose  of  magnesium  sulphate  (see  Dosage  Table) 
is  given  on  the  night  before  the  thymol  is  to  be  adminis- 
tered. With  the  more  intelligent  classes  of  people  the 
dose  of  salts  may  be  left  to  be  taken  at  bed  time.  The 
patient  should  be  advised  to  refrain  from  eating  supper, 
or  in  any  event  to  eat  only  a  light  meal,  avoiding  greasy 
foods. 

(2)  No  breakfast  is  to  be  eaten  by  the  patient  the 
following  morning.  At  the  time  agreed  upon  the  nurse 
is  to  call  on  the  patient  and  ascertain  if  the  dose  of  salts 
given  the  night  before  has  thoroughly  cleared  out  the 
alimentary  canal  and  if  the  patient  has  refrained  from 
food  as  directed.  If  these  conditions  are  found  favor- 
able, the  nurse  administers  the  first  dose  of  thymol,  and 
in  two  hours  the  second  dose. 

(3)  Two  hours  after  the  second  dose  of  thymol  is  given 
the   nurse    administers    a    dose   of  magnesium    sulphate. 


GENERAL   INSTRUCTIONS    FOR   NURSES  I7I 

Both  doses  of  thymol  and  the  dose  of  magnesium  sulphate 
which  follows  them  should  always  be  given  by  the  nurse, 
who  must  assure  himself,  before  leaving  the  vicinity  of 
his  patient,  that  the  last  dose  of  salts  has  acted  thoroughly 
and  has  cleared  away  the  dead  worms  and  the  thymol 
from  the  alimentary  canal. 

(4)  While  the  nurse  is  administering  treatment  at 
other  nearby  homes,  the  patient  should  be  instructed  to 
summon  the  nurse  if  any  untoward  symptoms  develop, 
and  to  notify  him  if  the  dose  of  salts  does  not  act  within 
two  hours  after  it  is  given,  in  which  case  the  dose  is  to 
be  repeated. 


VI 
CONTRACT  WITH  SUBORDINATE  EMPLOYES 

I,    the    undersigned,     accept    employment    with    the 

Ankylostomiasis  Commission   at  a 

monthly  salary  agreed  upon  between  the  medical  di- 
rector and  myself  in  the  presence  of  witnesses,  under  the 
following  terms  and  conditions: 

First,  the  services  which  I  am  to  perform  will  be  under 
the  medical  director  of  the Anky- 
lostomiasis Commission  and  consist  of  any  duties  he  may 
assign  to  me. 

Second,  I  am  employed  on  the  condition  that  I  shall 
be  able  to  perform  to  the  satisfaction  of  the  medical  di- 
rector the  duties  assigned  to  me,  exercising  at  all  times 
due  diligence  and  faithfulness  to  duty  in  all  services  re- 
quired of  me. 

Third,  in  case  I  am  not  able  to  accomplish  such  duties 
as  are  assigned  to  me  to  the  satisfaction  of  the  medical 
director,  or  am  insubordinate,  or  for  other  just  cause 
am  dismissed,  I  agree  to  accept  two  weeks  as  sufficient 

notice  of  my  dismissal  from  the  service  of  the 

Ankylostomiasis  Commission,  and  to  waive  all  claims  to 
a  longer  term  of  notice  of  dismissal  or  to  salary  for  any 
time  beyond  the  two  weeks  for  which  this  notice  is  given. 

Fourth,  I  agree  that  misconduct  and  absence  from  work, 
unexcused  by  the  medical  director,  will  entail  a  deduc- 
tion from  my  monthly  salary. 

Fifth,  I  further  agree  that  in  case  I  resign  from  the 

employ    of   the Ankylostomiasis 

172 


CONTRACT    WITH    SUBORDINATE    EMPLOYES       I73 

Commission  I  shall  give  the  medical  director  two  weeks' 
notice  of  my  resignation  from  the  service. 

Signed 

Title  of  Employe 

Note:  In  case  of  nurses  a  sixth  clause  is  added: 
Sixth,  I  further  agree  to  provide  myself  with  a  bicycle 
or  such  other  means  of  travel  as  may  be  required  of  me 
by  the  medical  director  of  the Anky- 
lostomiasis Commission,  and  to  maintain  the  same  at  my 
own  expense  throughout  my  term  of  service  as  nurse  in 

the    force    of    the Ankylostomiasis 

Commission. 


VII 
SAMPLE  CIRCULAR  USED  IN  BRITISH  GUIANA 

HOOKWORM   DISEASE 

YOU  MAY  BE  TREATED  AND  CURED  FREE  OF  COST 

The  International  Health  Board,  working  with  the  G)lonial  Government, 
will  give  FREE  examination  and  FREE  treatment  for  HOOKWORM  DISEASE 
to  every  man,  woman,  and  child. 

In  each  district  will  be  established  a  FREE  DISPENSARY  with  a  force  of 
skilled  men  to  examine  the  people,  and  a  PHYSICIAN  in  charge  who  has  had 
wide  experience  in  the  treatment  of  this  disease.  Many  thousands  have  al- 
ready been  examined  and  treated  on  the  ElAST  and  WEST  BANKS  and  on 
the  EAST  COAST  from  KITTY  to  BUXTON  inclusive.  As  a  result  the  people 
in  these  areas  are  much  stronger  and  healthier  than  before.  Now  this  great 
boon  is  offered  to  you  for  the  first  time  FREE  OF  COST.  Investigations  al- 
ready made  show  that  about  six  out  of  every  ten  of  the  people  in  the  villages 
have  this  disease,  and  many  of  these  people  are  SICK  AND  WEAK  on  ac- 
count of  it. 

Many  of  the  ailments  of  which  people  complain  are  due  to  the  presence  of 
the  HOOKWORM  in  the  body,  where  they  may  exist  in  HUNDREDS  and 
where  they  BITE  THE  INTESTINES  and  SUCK  THE  BLOOD,  thus  sap- 
ping the  strength  and  vitality  of  their  victims.  The  symptoms  of  the  disease 
are  many.  Some,  but  NOT  all  of  them,  are  as  follows:  —  HEADACHE, 
DIZZINESS,  INDIGESTION  AND  DYSPEPSIA,  PALPITATION  OF  THE 
HEART.  KIDNEY  TROUBLE,  DROPSY,  PALENESS,  SHORTNESS  OF 
BREATH  —  which  may  be  so  severe  as  to  be  called  ASTHMA  —  CONSTI- 
PATION, WEAKNESS,  and  STOPPING  OF  PHYSICAL  AND  MENTAL 
GROWTH  and  DEVELOPMENT.  Often  the  symptoms  are  so  mild  for  a 
long  time  that  the  victim  does  NOT  SUSPECT  THE  PRESENCE  OF  THE 
DISEASE  UNTIL  GREAT  HARM  HAS  BEEN  DONE.  Therefore,  no  one 
can  consider  himself  safe  until  an  EXAMINATION  WITH  THE  MICRO- 
SCOPE shows  him  to  be  free.  We  often  find  people  who  think  they  are 
in  good  health   until  our  examination  shows  that  they  are  infected. 

The  HOOKWORM  lives  in  the  small  intestine  and  FEEDS  ON  THE 
BLOOD.  The  female  lays  hundreds  of  eggs  every  day.  These  never  hatch 
in  the  body,  but  must  be  passed  out  in  the  bowel  movements  and  deposited 
on  the  ground  or  they  do  not  hatch.  Those  which  are  deposited  on  the  ground 
hatch  into  worms  too  small  to  be  seen.  These  worms  live  in  the  soil  wherever 
the  ground  is  contaminated.  From  the  soil  they  usually  get  upon  the  feet  and 
pass  through  the  skin  in  a  few  minutes,  and  then  into  the  blood,  and  after  a  few 
days  they  have  found  their  way  into  the  small  intestine,  where  they  live  for 

174 


SAMPLE    CIRCULAR    USED    IN    BRITISH    GUIANA        1 75 

years  if  not  treated.  When  they  pass  through  the  skin  they  cause  sores  which 
itch  and  fester,  and  which  are  commonly  called  GROUND  ITCH  when  occur- 
ring on  the  feet.  So  it  may  be  said  that  ANYONE  WHO  HAS  HAD  GROUND 
ITCH  HAS  HOOKWORM  DISEASE.  However.  ONE  WHO  HAS  NOT  HAD 
GROUND  ITCH  MAY  HAVE  HOOKWORM  DISEASE.  This  is  true  because 
in  some  cases  the  worm  GETS  IN  THROUGH  THE  MOUTH  ON  VEGE- 
TABLES AND  FRUITS  WHICH  ARE  NOT  COOKED  BEFORE  BEING 
EATEN.  THE  WORMS  AT  THIS  STAGE  ARE  SO  SMALL  THAT  THE 
MOST  CAREFUL  WASHING  MAY  NOT  REMOVE  THEM.  On  this 
account  no  one  will  be  safe  from  the  disease  under  present  sanitary  conditions. 
SOME  OF  THE  RICHEST  AND  MOST  INFLUENTIAL  PEOPLE  IN 
DISTRICTS  WHERE  WE  HAVE  WORKED  BEFORE.  HAVE  HAD  THE 
DISEASE.  The  EIXAMINATION,  which  is  necessary,  consists  in  having  each 
individual,  from  the  youngest  to  the  oldest,  furnish  us  with  a  small  bit  of  bowel 
movement,  and  with  this  his  NAME,  AGE,  ADDRESS,  and  RACE,  for 
purpKJses  of  identification  and  record.  This  specimen  of  bowel  movement  is 
examined  by  an  expert  at  the  Dispensary,  and  if  HOOKWORM  EGGS  are 
found  we  know  that  the  person  is  infected,  and  treatment  is  given.  Our  men 
will  call  at  your  homes  and  give  you  small  boxes  to  collect  the  specimens  in, 
and  will  also  deliver  the  medicine  to  you  there  so  you  can  take  it  without  in- 
convenience. The  treatment  is  not  severe  and  the  cure  is  certain  and  speedy 
to  all  those  who  faithfully  take  treatment  regularly,  and  to  all  who  are  cured 
is  issued  a  certificate  of  health.  The  above  examination  also  enables  us  to 
determine  if  the  person  examined  has  any  other  worm  or  parasite.  The  OB- 
JECT of  our  work  is  to  ERADICATE  this  disease  entirely,  and  show  the 
people  how  to  protect  themselves  from  it  in  the  future.  To  do  this  it  will  be 
necessary  to  EXAMINE  EVERY  PERSON  in  the  territory  where  we  are 
working.  It  is  plain  to  any  one  that  we  would  fail  to  stop  the  progress  of  this 
disease  if  any  cases  were  left  untreated,  for  it  is  an  infectious  disease,  and  every 
case  originates  from  some  other  case. 

In  view  of  this  fact  it  would  seem  to  be  the  duty  of  every  official  —  every 
intelligent,  progressive  citizen  —  not  only  to  have  himself  and  his  entire  house- 
hold examined,  but  also  to  use  his  influence  with  his  friends  and  acquaintances 
to  secure  their  co-operation  in  this  work.  Already  more  than  A  MILLION 
people  have  been  treated  in  the  United  States  by  taking  advantage  of  the 
same  offer  which  is  being  made  to  you.  If  you  are  free  from  the  disease  you 
should  want  to  know  it.  If  you  have  the  disease  you  should  be  treated  and 
cured,  for  it  is  a  serious  malady  often  resulting  in  DEIATH,  either  directly  or 
indirectly,  and  no  person  who  has  it  can  ever  hope  to  be  as  useful,  happy,  or 
prosperous  as  he  would  otherwise  be.  Talk  this  matter  over  with  your  friends 
and  neighbours,  and  help  us  to  help  you.  You  are  cordially  invited  to  attend 
the  lectures  which  will  be  given  on  this  and  other  diseases  from  time  to  time, 
of  which  you  will  have  further  notice;  and  also  to  call  at  our  DISPENSARY 
and  see  the  work  actually  in  progress. 


VIII 
DESCRIPTION  OF  SPECIAL  CENTRIFUGE 

No.  19002  Double-Speed  Hand  Centrifuge  with  separ- 
ate clamp,  equipped  with  Stewart  panhead  with  nut  for 
fastening  to  centrifuge  shaft. 

Accessories: 

(1)  Special  glass  tubes,  heavy  wall,  open  at  both  ends  to  fit  clips 

ol  Stewart  panhead. 

(2)  Glass  funnels,  40  m.m.,  or  special  paper  funnels. 

(3)  Vials,  flat  bottom,  25  m.m.  high,  15  m.m.  in  diameter. 

(4)  Corks  for  Centrifuge  Tubes,  No.  O,  XXXX  quality. 


Fig.  24.  —  Special  cen- 
trifuge used  in  exam- 
ining specimens. 

{Left)  Shaft,  showing 
manner  of  clamping  to 
table. 

{Right,  above)  Stewart 
panhead  with  specimen 
tubes  in  position. 


INDEX 

PAGE 

Alcohol,  Solubility  of  Thymol  in .- 79 

Also 69,73,76,83 

Allowances,  see  Salaries 

American  Journal  of  Otology,  quoted 93 

American  Journal  oj  Physiology,  quoted 90 

Ankylostoma,  see  Hookworm 

Ankylostomiasis,  see  Hookworm  Disease 

Anthelmintics 16 

See  also  Oil  of  Chenopodium;    Thymol 

Antigua: 

Table  showing  per  capita  cost  of  hookworm  campaign loi— 102 

Results  of  treatment,  with  table  giving  percentage  remaining 

uncured 121-122 

Also 58 

Atropine: 

In  thymol  poisoning,  with  dosage 83 

Aural  Phenomena  in  Poisoning,  see  Oil  of  Chenopodium 

Aural  Phenomena  of  Chenopodium  Poisoning,  by  Dr.  Samuel  Seiton, 

quoted 93 

Balopticon,  see  Supplies 

Barbados 58 

Bausch  and  Lome  Optical  Co.,  Rochester,  N.  Y 64 

Bicycle 52 

Biggs,  Dr.  Hermann  M.: 

Member  International  Health  Board 5 

Bismuth,  see  Milk  of  Bismuth 

Blanks  and  Forms  Used  in  Intensive  Method,  see  Case 
Record  Book;  Census  Book;  Reports;  Treatment 
Book 

Branch  Offices,  see  Working  Staff 

Brazil 90 

British  Guiana: 

Use  of  iron  sulphate  in  soil  pollution 18 

Hookworm  control  begun 21-22 

Choice  of  Peter's  Hall  district 22 

177 


178  INDEX 

PAGE 

British  Guiana  —  continued 

Local  conditions  and  elements  of  population 22-24,  ^^3 

Changes  in  plan  of  operation 2$ 

Quarterly  average  of  persons  examined,  treated,  and  cured 27-28 

Technique  of  examinations,  with  comparison  of  methods S7~S8 

Methods  and  results  of  treatment  with  thymol 69-71 

Table  showing  per  capita  cost  of  hookworm  campaign loi 

Dr.  F.  E.  Field's  report,  quoted 108 

Results  of  treatment,  with  table  giving  percentage  remaining 

uncured 121-122 

Sample  circular  used  in  hookworm  campaign 174-175 

Also 58,  78 

Budget,  see  Reports 

BuTTRicK,  Wallace: 
Member  International  Health  Board , S 


Camera  Films,  see  Supplies 

Capsules: 

Preparation 88-89 

Cost  of  capsulating  thymol 166 

Number  required  for  one  gallon  of  chenopodium 167 

Also i6o-i6i 

Cardiac  Symptoms  in  Poisoning,  see  Oil  of  Chenopodium 

Caretakers,  see  Working  Staff 

Case,  Black  Sole  Leather,  see  Supplies 

Case  Record  Book: 

Description  and  use,  with  sample  page 126-13 1 

Castor  Oil: 

In  thymol  poisoning 83 

In  treatment  with  chenopodium 84, 85, 86, 90, 91, 93-94 

Cayman  Islands 58 

Census,  see  Nurses 

Census  Book: 

Description  and  use,  with  sample  pages 123-126 

Also 46 

Centrifuging: 

Description  of  machine  used 64,  176 

Table  showing  positive  findings  in  Trinidad 64 

Method  of  preparing  specimens  for  examination 64-67 

Importance  in  re-examination 67-68 

Number  of  specimens  handled  daily 68 

Also 58,  61,  63 

See  also  Laboratory  Technique;  Supplies 


INDEX  179 


PACE 


Ceylon 90 

Chemicals,  see  Sulphate  of  Iron 
Chenopodium,  see  Oil  of  Chenopodium 
Cheyne-Stokes  Breathing,  in  Poisoning,  see  Thymol 
Chief  Clerk,  see  Working  Staff 
Chief  Microscopist,  see  Microscopists 
Children: 

Dosage  of  thymol 69,  161 

Dosage  of  chenopodium 84 

Also 169 

Chinese,  in  West  Indies 24*  io3 

Chloroform 84 

Circular  on  Hookworm  Disease  Used  in  British  Guiana.  . .  174-175 
Clerical  Force,  see  Working  Staff 

CoLWELL,  Dr.  H.  S 88 

Containers,  Specimen,  see  Feces,  Examination  of;    Supplies 
Contingent  Fund,  see  Budget,  under  Reports 

Contract  with  Subordinate  Employes 40, 172-173 

Cost  Figuring,  see  Treatment,  Per  Capita  Cost  of 

Creole  Population,  in  West  Indies 103 

Demerara  River,  British  Guiana 22 

Diary,  see  Reports 

Digitalin: 

In  thymol  poisoning,  with  dosage 83 

In  chenopodium  poisoning 94 

Direct  Smear  Method,  see  Laboratory  Technique 

Director,  see  Medical  Director 

Dispensaries 38 

Districts,  see  Nurses 

Dock  and  Bass: 
Technique  of  examination  followed  in  British  Guiana 57 

Drugs i3»  4^ 

See  also  Budget,  under  Reports;  Names  of  Drugs 

Dutch  Guiana: 

Javanese  among  population 24 

Table  showing  per  capita  cost  of  hookworm  campaign loi 

Results  of  treatment,  with  table  giving  percentage  remaining 

uncured 121-122 

Also 58 

East  Indian  Population,  in  West  Indies 23,  24, 44, 103 

Educational  Work,  see  Lectures;  Literature 


l8o  INDEX 

PAGE 

Egypt 90 

Embree,  Edwin  R. 

Secretary  International  Health  Board 5 

Employes,  Contract  with  Subordinate 40,  172-173 

Epsom  Salts,  in  Thymol  Poisoning 83 

Equipment,  see  Budget,  under  Reports;  Supplies 
Examination,  Methods  of,  see  Laboratory  Technique 


Fats  and  Oils,  Solubility  of  Thymol  in 79 

Feces,  Examination  of: 

Various  techniques S5~S7 

Method  of  preparing  specimens 59 

Also 3S.  44. 45-46, 48,  S3,  54, 

S^^  also  Centrifuging;  Laboratory  Technique 

Ferguson,  Dr.  J.  E.  A 22, 69 

Ferrell,  Dr.  John  A.: 

Director  for  the  United  States 5 

Field,  Dr.  F.  E.,  quoted 108 

Also note  57,  78 

Films,  Camera,  see  Supplies 
Flexner,  Dr.  Simon: 

Member  International  Health  Board 5 

Forms    Used    in  Intensive  Method,  see  Case  Record  Book; 

Census  Book;    Reports;    Treatment  Book 
Funnels,  see  Supplies 

Gastro-intestinal  Symptoms  of  Poisoning,  see  Oil  of  Cheno- 

podium;  Thymol 
Gates,  Frederick  T.: 

Member  International  Health  Board 5 

Geographical  Area  Report  on  Completed  Work,  see  Reports 

Georgetown,  British  Guiana 22 

GoRGAS,  Gen.  William  C: 

Member  International  Health  Board 5 

Grenada: 

Interval  between  treatment  and  re-examination 88 

Table  showing  per  capita  cost  of  hookworm  campaign lOl 

Results  of  treatment,  with  table  giving  percentage  remaining 

uncured 121-122 

Also 58 

Heiser,  Dr.  Victor  G.: 

Director  for  the  East 5 


INDEX  151 

Hookworm:  page 

Stages  of  life-cycle I3~I4 

Chemicals  and  fire  in  destruction  of  larvae  in  soil 17-18 

Also SO 

See  also  Soil  Pollution 
Hookworm  Chart,  see  Supplies 
Hookworm  Disease: 

Distribution  and  control 13 

Theory  of  prevention 14 

Problem  of  eradication I4~IS 

Presentation  of  story  under  intensive  method 3 1-32 

Basis  of  diagnosis 55 

Persons  medically  unfit  for  treatment 72,  169-170 

Also 16 

Hookworm  Disease,  Relief  and  Control: 

Necessity  of  microscopic  examination 15 

Co-operation  of  patients IS"!^ 

Installation  and  use  of  sanitary  conveniences 16-17 

Danger  of  re-infection 17 

Soil  pollution  and  prevention 95 

Method  of  reckoning  cost  of  campaign  in  West  Indies 99-100 

See  also  Intensive  Method  in  Hookworm  Control;    Soil 
Pollution 

Hookworm  Disease,  by  Dock  and  Bass 57 

Howard,  Dr.  H.  H. 

Director  for  the  West  Indies 5 

Intensive  Method  in  Hookworm  Control: 

Definition  and  plan  of  operation 20-2 1 

Publicity  work 21,  33-35 

Begun  in  British  Guiana 21-22 

Size  and  composition  of  working  staff,  with  time  required  for 

completion  of  campaign  in  given  area 26,  28-29,  37~39 

Selection  of  area 26-27 

Campaigns  preceded  by  surveys 27 

Educational  aspects  and  purposes 3i~3S>  104-105 

Work  of  nurses 3S~36 

Required  treatments 46-47 

General  applicability 103-104 

Co-operation  of  population 105 

Consideration  shown  to  patients 105-106 

Blanks  and  forms 123 

See  also   British  Guiana;  Lectures;  Literature;  Medical 

Director;  Microscopists;   Nurses;  Trinidad;  Working 

Staff 


l82  INDEX 

PAGE 

International  Health  Board: 

Officers,  Members,  and  Administrative  Staff S 

Co-operative  efforts  with  states  and  countries 18-19 

Intensive  method  in  hookworm  control 20 

Work  in  British  Guiana 21-23 

Offers  services  for  purchase  and  shipment  of  supplies  to  foreign 

countries,  with  list  of  same 165-167 

Also 56, 95. 96 

Iron  Sulphate,  see  Sulphate  of  Iron 

Javanese,  in  Dutch  Guiana 24 

'Journal  of  American  Medical  Association,  quoted 86-87 

Kodak,  see  Supplies 

Laboratory: 

Relation  to  curative  work 55 

Force  and  technique  in  West  Indies 56 

Also 35.  39. 44 

See  also  Supplies 
Laboratory  Technique: 

Based  on  work  of  Dock  and  Bass 57 

Comparison  of  direct  smear  and  present  method S7~S8 

Success  in  development 58-59 

Recording  and  arrangement  of  specimens 59 

Preparation  of  smears  and  work  of  examination 60-61 

Advantages  of  direct  smear  method 61-62 

Modifications 62-63 

Number  of  smears  necessary  for  examination 63 

Table  showing  average  number  of  positive  findings 63-64 

Number  of  specimens  handled  daily 68 

See  also  Centrifuging;    Feces,  Examination  of;  Micros- 

COPISTS 

Lantern  Slide  Carrying  Case,  see  Supplies 

Lantern  Slides,  see  Lectures;  Supplies 

Latrines: 

Installation  in  hands  of  local  government 19 

Phase  of  educational  work 33 

Noted  in  census  report 53 

House-to-house  survey 9S~96 

Types 96-98 

Record  of  improvement  in  case  record  book 126-127,  130-13 1 

Classification  in  census  book 123 

See  also  Soil  Pollution 


INDEX  183 

Leather  Case,  see  Supplies  pace 

Lectures: 

In  opening  campaign 31,  33-35 

By  Medical  Director,  to  new  nurses 50 

Recorded  in  diary 144 

Literature,  Distribution  of 34-3S>  144 


Magnesium  Sulphate,  see  Sulphate  of  Magnesia 

Medical  Director: 

Management  of  working  stafF 37~40 

Relation  to  government 40-41 

Relation  to  people 4i~42 

See  also  Working  Staff 

Methods  of  Examination,  see  Laboratory  Technique 

Meyer,  Ernst  C: 

Director  of  Surveys  and  Exhibits 5 

Microscopes,  see  Supplies 

Microscopic  Laboratory,  see  Laboratory 

Microscopic  Report  Sheets,  see  Reports 

Microscopic  Technique,  see  Laboratory  Technique 

Microscopists: 

Duties  of  chief  microscopist 43~44 

Duties 44 

Selection  and  training 44~4S 

Salary 51 

Work  in  standard  technique 60-63 

Milk  of  Bismuth,  in  Treatment  for  Gastric  Irritation.  .  .       81 

Milk  Sugar,  see  Sugar  of  Milk 

Minim,  Unit  of  Measure 88,  89 

Morphia: 

Use  in  thymol  poisoning,  with  dosage 83 

Murphy,  Starr  J.: 

Member  International  Health  Board S 

Nausea  in  Poisoning,  see  Thymol 

Neuro-toxic    Symptoms    of  Poisoning,   see   Oil    of   Cheno- 

PODIUM 

Nicaragua 9° 

Night  Soil,  see  Soil  Pollution 
Nitroglycerine: 

In  thymol  poisoning,  with  dosage 83 

Non-treatable  Cases 16, 72, 169-170 


184  INDEX 

Nurses:  ''*°'' 

Consolidation  of  districts 29-30 

Publicity  work 35-36 

Care  of  treatment-books,  supplies,  and  records 42-43 

In  charge  of  district 45 

Census  taking 45-47.  53-54 

Treatment  of  infected  persons 46-47 

Duties  of  chief  nurse 47-48 

Selection  and  qualifications 48-49 

Training  in  administration  of  drugs 49-50 

Salary 51 

Instructions  regarding  non-treatable  cases 169-171 

Directions  for  administering  treatments 170-171 

See  also  Case  Record  Book;  Census  Book;  Diary,  under 
Reports;  Non-treatable  Cases;  Reports;  Treatment 
Book;  Working  Staff 

Nurses'  Report  Sheets,  see  Reports 


Office  Equipment,  see  Budget,  under  Reports 

Oil  of  Chenopodium: 

Results  of  use  in  West  Indies 84 

SchufFner  and  Vervoort  method  of  treatment 84 

Weiss  method  of  treatment 85, 91 

Recommendations   by  Uncinariasis  Commission  to  Orient  on 

routine  of  treatment .' 85-86 

Comparison  with  thymol,  summarized  from  Report  of  Uncina- 
riasis Commission  to  Orient 86-87 

Interval  between  treatment  and  re-examination 87-88 

Given  on  sugar 88 

Preparation  of  capsules 88-89 

Relation  of  drop  to  minim 89 

Cases  of  poisoning 89-91 

Gastro-intestinal  symptoms  of  poisoning 91-92 

Neuro-toxic  symptoms  of  poisoning 9I>  92-93 

Aural  phenomena  in  poisoning 93 

Remarks  of  Salant  and  Livingston  on  depressing  quaHties 93 

Treatment  for  poisoning 93-94 

Cardiac  symptoms  in  poisoning 94 

Value  as  a  vermifuge 94 

Capsules  required  for  one  gallon 167 

Contraindicated 169 

Also 49 

See  also  Non-treatable  Cases;    Supplies 


INDEX  185 


PACE 


Oils  and  Fats,  Solubility  of  Thymol  in 79 

Oliver,  Sir  Thomas 17-18 

Panama 90 

Per  Capita  Cost,  see  Treatment,  Per  Capita  Cost  of 

Peter's  Hall  District,  see  British  Guiana 

Poisoning,  see  Non-treatable  Cases;   Oil  of   Chenopodium; 

Thymol 

Portuguese,  in  West  Indies 24, 103 

Pregnancy,  and  Treatment  for  Hookworm  Disease, 

72,83-84, 169, 170 
Prest-O-lite  Gas  Tanks,  see  Supplies 
Publicity  Work,  see  Intensive  Method  in  Hookworm  Control; 

Lectures;    Literature;   Nurses 
Purgatives,  see  Castor  Oil;   Epsom  Salts;   Senna;   Sulphate 

OF  Magnesia 

Reports: 

Microscopic  Report  Sheet: 

Explanation  and  sample  page 131-133 

Nurses'  Daily  Report  Sheet: 
Explanation  and  sample  page 134, 138-139 

Nurses'  Weekly  Report  Sheet: 

Explanation  and  sample  page 135, 140, 141 

Nurses'  Weekly  Summary  Report  Sheet: 

Explanation  and  sample  page 135,  142, 143 

Diary: 

Record  of  educational  work,  with  sample  page 144-146 

Geographical  area  report  on  completed  work 146, 148-149 

Quarterly  report  on  completed  work  with  sample  page. .  146, 150-15 1 
Quarterly  report  on  work  in  progress,  with  sample  page. .  147, 152-153 
Special  monthly  report  for  Regional  Directors,  with  sample  page 

147,  154 

Narrative  report 147,  155 

Budget: 

Explanation,  and  sample  form ISS~IS7 

Salaries 158-159 

Office  equipment 159 

Scientific  equipment 160 

Drugs 160-161,  164 

Contingent  fund 164 

Quarterly  and  yearly  financial  reports,  with  sample  form 162-164 

Rockefeller,  John  D.,  Jr.: 

Member  International  Health  Board 5 


l86  INDEX 

PAGE 

Rockefeller  Sanitary  Commission 23 

Rose,  Wickliffe: 

General  Director,  International  Health  Board 5 

Also 22 

St.  Lucia: 

Table  showing  per  capita  cost  of  hookworm  campaign lox 

Results  of  treatment,  with  table  giving  percentage  remaining 

uncured 121-122 

Also 58 

St.  Vincent: 

Table  showing  per  capita  cost  of  hookworm  campaign loi 

Results  of  treatment,  with  table  giving  percentage  remaining 

uncured 121-122 

Also 58, 103 

Salant  and  Livingston: 

Remarks  on  depressing  qualities  of  chenopodium 93 

Salant  and  Nelson,  Toxicity  of  Oil  of  Chenopodium,  quoted. . .       90 

Salaries 51-52 

See  also  Budget,  under  Reports 

Salines,  see  Epsom  Salts 

Salt,  see  Sulphate  of  Iron 

Schuffner  and  Vervoort: 

Method  of  treatment  with  chenopodium 84 

Scientific  Equipment,  see  Budget,  under  Reports;    Supplies 

Seiton,  Dr.  Samuel,  quoted 93 

Senna,  in  Thymol  Poisoning 82 

Sewage  Disposal,  see  Latrines;    Soil  Pollution 

Smear  Method,  Direct,  see  Laboratory  Technique 

Society  of  Tropical  Medicine  and  Hygiene,  quoted 17 

Soda,  in  Treatment  for  Gastric  Irritation 81 

Soil  Pollution: 

Necessary  to  hookworm  infection 14 

Installation  and  use  of  sanitary  conveniences 16-17 

Prevention  in  West  Indies 16-18 

Importance  of  prevention 95 

Survey  of  latrine  accommodations 9S~96 

See  also  Latrines 

Southern  States: 

Thymol  treatment 74 

Fatal  cases  of  chenopodium  poisoning 89-90 

Specimen  Containers,  see  Feces,  Examination  of;    Supplies 

Staff,  see  Working  Staff 

Standard  Method,  see  Laboratory  Technique 


INDEX  187 


PAGE 


Stewart  Panhead,  see  Centrifuge 

Stimulants  in  Thymol  Poisoning 83 

Strychnine: 

In  thymol  poisoning  with  dosage 83 

In  chenopodium  poisoning 94 

Sugar,  Oil  of  Chenopodium  given  on 88 

Sugar  of  Milk 

Combined  with  thymol 77-78,  160-161 

Sulphate  of  Iron 

In  destruction  of  hookworm  larvae  in  soil 17-18 

Sulphate  of  Magnesia: 

In  treatment  with  chenopodium 73,  81,  86,  90,  91 

Annual  estimate  of  amount  for  one  unit  of  force  and  cost  of  same.      161 

Dosage  for  adults  and  children 161 

Also 169,  170-171 

See  also  Supplies 

Sumatra: 

Weiss  method  of  administering  chenopodium 8S>9I 

Supplies: 

Procurable  through  International  Health   Board,  with  list  of 
prices 165-167 

Talquist,  Hemoglobin  Scale  Books 165 

Technique,  see  Laboratory  Tecnhique 

Thymol: 

Methods  of  administering,  and  dosage 69,  71-72 

Amount  necessary  to  cure  one  adult '. . .  .70,  i6a-i6i 

Results  of  treatment   by  daily  dose  method   in   Peter's   Hall 

district 70-71 

Maximum  dose  for  adult 71 

Persons  medically  unfit  for  treatment 72 

Treatment  preceded  by  thoracic  examination 72 

Directions  for  treatment  by  weekly  dose  method 72-74 

Intervals  between  treatment  and  re-examination 74~7S 

Number  of  treatments  necessary  and  percentage  of  cures 7S 

Safety  as  a  drug 76 

Combined  with  sugar  of  milk 77~7^ 

Toxic  effects  and  solubility 79-8o 

Symptoms  of  poisoning 80-82 

Treatment  for  poisoning 82-83 

Use  during  pregnancy 84 

Comparison   with   chenopodium,  summarized   from   Report   of 

Uncinariasis  Commission  to  Orient 86-87 

Capsule  form  and  cost  of  same 160-161,  166 


l88  INDEX 

PAGE 

Thymol  —  continued 

Annual  estimate  of  amount  for  one  unit  of  force  and  cost  of  same 

160-161 

Dosage  for  children 161 

Contraindicated 169 

Directions  to  nurses  for  treatment 170-171 

Also 49-50 

See  also  Non-treatable  Cases;    Supplies 

Tobago 58 

Toothpicks,  in  Laboratory  Technique S9>  60 

See  also  Supplies 

Toxicity  of  Oil  of  Chenopodium,  by  Salant  and  Nelson,  quoted 90 

Treatment,  Per  Capita  Cost  of 99-102 

Treatment  Book: 

Description,  with  sample  page 134, 136-137 

Treatment  of  Hookworm  Infection,  by  Uncinariasis  Commission  to 

the  Orient,  quoted 86-87 

Trinidad: 

Quarterly  average  of  persons  examined,  treated,  and  cured.  .  .  .27-28 

Technique  of  examinations,  with  comparison  of  methods 57~5^ 

Table  showing  positive  findings  after  centrifuging 64 

Observations  on  use  of  thymol,  with  table  giving  percentage  of 

cures 76-78 

Interval  between  treatment  with  chenopodium   and   re-exami- 
nation         88 

Table  showing  per  capita  cost  of  hookworm  campaign loi 

Dr.  Washburn's  report,  quoted 108 

Result  of  treatment  by  intensive  method,  with  table  giving  per- 
centage remaining  uncured 121-122 

Also 58, 68, 103 

Tubes,  see  Supplies 

Uncinariasis,  see  Hookworm  Disease 
Uncinariasis  Commission  to  the  Orient: 

Recommendations  on  use  of  chenopodium 85-86 

Summary  of  report  on  comparative  value  of  thymol  and  cheno- 
podium   86-87 

Recommendations  on  interval  between  treatment  with  cheno- 
podium and  re-examination 88 

Experience  on  toxicity  of  chenopodium 90-91 

Unit  of  Force,  see  Working  Staff 

Vermifuges,  see  Oil  of  Chenopodium;    Thymol 
Vertigo,  in  Poisoning,  see  Oil  of  Chenopodium;   Thymol 


INDEX  189 

Vials,  see  Supplies  p^^^ 
Vincent,  George  E.: 

Chairman   International  Health  Board 5 

Washburn,  Dr.  B.  E.: 

Observations  on  use  of  thymol  with  percentage  of  cures 76-78 

Results  of  experiments  with  chenopodium 88 

Report  of  ankylostomiasis  campaign  in  Trinidad,  quoted 106-108 


Also. 


.note  57 


Weiss  Method  of  Treatment  of  Chenopodium 85,91 

Welch,  Dr.  William  H. 

Member  International  Health  Board 5 

West  Indies: 

Prevention  of  soil  pollution 16-18, 95 

Elements  of  population 24, 103 

Temperament  of  population 26 

Rate  of  hookworm  infection 27 

Difliculties  in  organizing  laboratory  force 56 

Method  of  reckoning  per  capita  cost  of  campaign,  with  table.  .99-102 

Feasibility  of  intensive  method 103-104 

Also 40, 62,  90 

Sif^a/jo  Intensive  Method;  Oil  of  Chenopodium;  Thymol; 
Working  Staff;    also  Names  of  Islands 

Working  Staff: 

Efforts  concentrated  on  small  area 26-27 

Results  in  Trinidad  and  British  Guiana 27-29 

Size  and  elements 37~38 

Cost  of  maintenance  and  method  of  conducting  work 38 

Concentration  of  efforts 38-39 

Branch  offices  established 39 

Duties  of  clerical  force 42-43 

Duties  of  caretakers 51 

•  Salary  of  chief  clerk 51 

Number  of  infected  people  treated  in  one  year 160 

See  also  Medical  Director;    Microscopists;    Nurses 


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